DOC request three complete - Cannabis Defense Coalition

2538475797
FlAGe: 62
STATi O;:WASHING'1'ON
DEPAR110IENT OF CORRECTIONS
AUTHORIZATION FOR DISCLOSURE
OF HEALTH INFORMATI.ON
.To be filled out by ceo:
OFFEllOI!R Le. CATA:
~ _______ ,--_, hereby authorize the Yle or dl~osu ... of my health lnformatlon
The following individual orofisnization fa authorized. to make' the disclosure:
ADO~s!~
'jfi ~~~ i2~:Ji~- ~~f~ ~~ j'~C)~'
. ~C·lI.n.Jk...J::$,J. ~ c:t~Q. 2 . .
, .' ,thr£:. (Pi; 'di:-.. ~ t ~~;
. - T!'t~ type and date(s) of information to be used or disclosad is a.s follows:
, 1. The aceompallyln9 MedIcaL Martju~na JuStlflc;rtJon 10rm. .
_. 2. Any other information requested by the Medic.al Dlrec;tor, Washington State Department !'f CorrectIons.
" related to my prGScrlptJon for med.Jcal mariluana. ' ' ' , .
Purpose fcIr dlselQ$~re: To d.etermine the legitimacy of the patient's ctalm of a ~eed to use medical marJjUana
I understand that the inform~tion In my health record may Include InfOrn:latlon relating to sexiJaJly'transmftted
"infections, Acquired Immunodeflctency Syndrome (P,.ICSl, or Human Immunodeficl,noy'v'lru6 (HIV). It may also
include lnformaflon about behavioral or mental health 'I=r:-.rices ami treatment for alcohol and dlllg abuse:, .
-- This lnformaUon may be dledo-sed to and used by the -following Indl'lidual or organIzation!
NAME: Medlc:ar Director
ACORf:SS: Wa5hlngton State Department of CoTTGQtiona
Fax 360 586-9060-
.'
I u nders!end that I have a rl9nt to revoke thl~ ~uthorilatio". at any time. I unde~lend that If I rev~ke this,
. :alithorization I must do so in writing ~nd p'~elJtmy written revix:¢.ion'tc! the Health !nfqrmati6n· Management
Ceparlmen~ I· understand that th~ revocatioo will not apply_ to Information tHat -Me already been releaSed in
response to 1tIis authOrization. Unless otheiWise revoKSd, ij1\s au!l1ori;z:ation will expire 01) the follOWing date, event,
or condition; At the. tarmjnBtI~n of the, (if lett blank, authorization will exPire six (6) months from signing). _
patient's supervfslon by the -
," .
Wlahl~gton St&~ Department
of eorrectionc .
I understand that authorizing the disclosure ~~Jt~Ji!Llnto1!natlon Is vo[un~_ • .ig~rue.6.l$~_tp_sJgnJ!liliL.... _____ -"--_
authorization. I need !'lot sign this farm In order to assure natmant.- I understand that I may Inspect or,copy the
Inro~tlon to be usee! or disclosed, as provided In CFR 164.~~4 and. RCW 70.02. 'understand t!'1at any dlsclO$ure.
of Informellon cames yJltti It the potential for lin unauthorlzaG redlsdosl.l1'S at'Id may not be prot=ctaell:ly federal or
S1ate ponlidentlall~ ru,les. If 1 have' questio!'l$ about disclosure of my health Infcrmation, I may eontact the .
RHIT/deslgnee of the facility: -'n"""a=-_______ --:--__ -..:.._~_'___ _
_ po~ 13--035 Rav, O!l1~Joa) OO,C SOO:020DOC 840.020 DOC 6(0.020 L5QAL
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PDU-6655-3 000465