DOC request three complete - Cannabis Defense Coalition

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OFFENDSII l.g. gllTA:
I' (~ ~~l~~~~~~~HcGJ~~cnoNs' .
M~dlclnal Use of M.rijuana Verification
~C_O_:_· __________________ ~ __ ~~liIIIf~:_inn __ ~ ____-JI.D.O.C.N.u.m~~
To be fllied out by Prascrlbar!
__ r ____ ~'1
Dear prescriber, .
. By state statute the Washington State Oepartment· of Corrections is chargedwtth the respo.nsibmty to supervise some
offenders after they have.be..n.c=~lcted p~ ~ felony. Th~ above named patient Is c,urrently under supervision by the
Department Supervision Is' designed to help th~ o~ender avoid those environments or sltuatlen~ that lead t~ tJ:1eir criminal
~t;avior. Often llfi!:it dr\.lS uee 15 a contributing facler han indIvidual's crimloallty: Aa:crdingly It's usual. tMt rl'le tourt or .
the Dep~rtment of CcrrectiohS will impose a cendition of supervisIon that tha offendtlr not use, or possess illicit drugs,
including marijuana. tnls offender has claimed that they have acondl~on rorwtllch the medicinal use of marIJuana /'las .
l:Ieen prescribed. The below verification Is to determine·the legitimacy of their olalm. Thank you in adVance to~ your
assistance. If yOIl have questions "Iea~e hlel free to personally contac;t the Medical Director of'the Department· at' (360)
72.5·8700, i .. / .
. 1. 1& this patient un~~r yOl,lr oara ¢' Ves 0 No
. 2. Are you prescribing I'fledical marijuana for his ~itlent due to &l diagnosis of Acquired
Immunodefioleri~y Syndrome (AIDS) . .
Dves 91fo
3,'
;, If the answer to question 2 is "Yes', does he/she l'Ieve anorexia Dyes c:;;}rq"a
b. 11 the anMf to question Za Is "Ves"/does he/she have weight loss DVes DNO
Are you prescribing' mEldic~1 marijuaMa tor this patient due to' nausea 'Sr1d vomiting aSSOCiated
with cancer chemo1tI(;~rapy . DYes ~.
I!. 11 the answer to quc3tion a 1$ ·Yet!.", has the petlentfalled to rOGipond to conventional .
a~tiemetic treatments .. .
Dns . !5No
b. If the ansWer to Qumon :3~ is "Yes·, pleaSe describewhat these treatments were (medlC!aUon, dose,
duration): . ': . '. .' . . . .
. . .
e,' What is the planned SChedUle qf chemotherapy
. " ~ . .
. 4:Whna of'! cgmmunlty 5upsrvis.ion (·paiol~~' the Department of COIT~tiOi1S enly authcrizl!I! the ~o
use of!:l1e flt3i synthetic formulation of marijuana. If tI1e Department authoriZes this patienfs 0 Yes I!:::l NO
. 1.15" af medical marijuana, will you be proscrtblng only tl'Ie orsl synthetic fgrrnuletlon7
s. The p~ij~nrs·accompanying Release of Inform~~on euthQ~Ii':es you 1i:l prOvide tha
Oepartment with current an~ future information related to this issue. 00 you agree to notify O· Yi • n...rr:;".
the Depertr:nent's Medical Drrector of any change~ In your answers above . as. ~ I.I!r l'~...:. A: P. .
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PDU-6655-3000464