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Jan. 4. 2009 12:40PM CBR Medical Inc .. DEU-JU-cUUH Ul:JH pM DUG GG DtP ntu P. 4 . n",g Nov. 26. 2008 4:52PM. COR Medical Inc. 380 586 0252 No. 2927 No. 2426 P. 5/13 p, lJr. II to be flilfild out by Prescriber: -- 1PateOf:i;jh - ~mber ._'-J ~_I"- __ . __ Dear P(JGCrlber. . Ely stale gtatute the Washinalan state Department of COrrecliOflS Is chw>lsd with the resOOhliibilllJl to BI!P€!fV;S() t;llnw offendors after they have been convicted (If R. f~hmy, The 3boVa haulod patient is clJITentiy under supervision by the O~partment 8L1pt.rv~!Q!1 ~ designed to tlEllp the orrel,der aVOid those environmenls or situations that lead to their criminal . ·bel1aviOt'. Often ~lic!t drug use Is a contributing fattor in
Jan, 4, 2009 12:41PM CBR Medical Inc, DE0-ju-~uutl·Ul·;qu rrt Duu uu v~r btU 360 586 0252 Nov',26, '2008 4:52PM CAR MnJical Jn~, NO,.2927 'p p, 5 . "l,."G , U;I l.' ......... Medlenl Dlrl,.l(;tor Health Services Division '. WashIngton State Deparlm~nt of Corte(l{lona PO 801\411:1.3 Olympia, WA9S504--21.13 To lilt filled om liy OOC Physician: I have reviewed·this vcriftol'l!lon fo!!!! ~rt iin~ !hilt Ulla gf mr.:dlmdllJll:uiJUfll'lhl lly this P!ltl~flt . (chack.o"!!) I [J ill []ffs not . ~tJ ..' . MrwJtcnt wilh OOCPolicy. . f.:J~A. ~·;Skv~ ~~'\.(Mt\). (l6IkfM-""-""~ .. v~~, .. ,,L -I'hyi!l~an's Name (t'r~ -- .- " pl'lsiclan', Sigrr~ .- '- Instructions to DOC Physician: When form is complete: 1 , ~mail your finding "",bovs ItIlhe Assistant Secretary for Community Corrections i File this form and the ~ccompanying Release of Information in '-lPl'!!'ty fllO a ComrOlIOity Corrections HeelIt!1 Hm;nlll. " ... • l!lb!t~ I~ (RCW 70.112; R~ 10,24,105; RCW 71.0S$O; andrarreder.ill r~glllatlom; (42 CFR Pori 2; 4S CF~ f'lII'l184t prQ/libil I;{isc!cs\lre 0' Ihb inf..rmlltion wit/1aut tho IPlIcifi,;;WIit1l1n ~QI1~'\1. nfln~ Il",.nn towh"", II ~flru.im'. Dr 1m aU1IUI'1I'';o,I permitted !!y Iav;. DOC 14-llS3 (Rev. 1(J1/08) \Joe 3!l(l,IWU '. PDU-6655-3000470
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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STATE OF WASHINGTON DEPA'RTMENTOF C
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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I I do ncit want to ruffle feathers
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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PRIMARY CARE PHYSICIAN AND LOOKED O
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3. High Non-Violent 4. Moderate, an
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to be processed now. If this was re
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Stern, Marc F. 'Dir Hlth Svc' (~OC)
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I J i Date License type: Prescriber
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3115 E. Mission Ave Spokcme, WA 992
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J STATE OF WASHINGTON DEPARTMENT OF
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Scott L. Havsy, DO, DAApM -Board Ce
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Page 495: Documentation of Medical Authorizat
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