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Dec. 30. 2008 12: 2'1PM CBR.Medical Inc. No. 2867 P. 2 'Orrt!NDeR I.ll, L1A I A: STATE OF II'JASHIMI!ITON DEPARTME~OF CORRECTIONS disclosure of my health information or organization is authori;2:6d to make the disclos!Jre: 'l:: '") ,( NAMf:: C i e··,,· .... L)' l~'-' . "'~ . e ('1 (- c_ .~ .x .-\,. f\' C .-:;:>. '- -:•• ' '. ADDRE:SS: ~.' "!"4': •...;> \ \ ~., k ,4,'1/ ~;;" ~J\C::1t:, __,_ "v-L ..,..... -:-R;:L ... ) .,. "- .:-~ t l ·,110 I.l) , t ',.'" ,.\.._) 1.,,,- n" ft \.~1 'i~' (''\.i r· .!.~:. " .. . --'----. ...-,----- ._--... _-- ! understand that the information in my health record may include information relating to sel
STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS P.O. Box -tI 116' Olympia. Washingtoll 98504-1126' FACSIMILE TRANSMITTAL SHEET TO: Melissa McGhee COMPANY: FAX NUMBER: 509-340-2710 PHONE NUMBER: FROM: . Monica Distefano DATE: DECEMBER 30, 2008 TOTAL NO. OF PAGES INCLUDING COVER: 3 ,SENDER'S PH,ONE NUMBER: 360-725-8796 SENDER'S FAX NUMBER: 360-586-0252 o URGENT X FOR REVIEVV .0 PLEASE COMMENT 0 PLEASE REPLY' 0 PLEASE RECYCLE NonS/COMMENTS:, Monica DistefanO . Executive Secretary 360':725-8796 PDU-6655-3000474
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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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Distefano, Monica J. (DOC) From: Se
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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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DoCumentation of Medical AuthoriZat
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STATE OF WASHINGTON DEPA'RTMENTOF C
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j I Documentation of MedicarAuthcir
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Chapter 69.51 A RCW: Medical marij1
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Chapter 69.S1A RCW: Medical marijua
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Chapter 69.511). RCW: Medical111ari
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Prescriber's Name (Print) License#:
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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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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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Wheeler, Judine L. (DOC) From: Sent
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Prescdbar's Name (pnnt) . Prasc~jje
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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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Distefano, Monica J; (DOC) From: Se
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I FW: 380200 Community Supervision
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Distefano, Moriica J. (DOC) From: .
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E.... KIOSK reporting may be used i
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to be processed now. If this was re
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Documentation of Medical Authorizat
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Distefano. Monica J. (DOC) From: Se
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11/06/2008 13:05 - PAGE ./"""-1. II
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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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Distefano, Monica J: (DOC) From: Se
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STATE OF WASHINGTON . DEPARTMENT OF
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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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3115 E. Mission Ave 'Spokane, WA 99
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OFFENDER 1.0. DATA: STATE OF WASHIN
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OFFENDER 1.0. DATA: STATE OFWASHING
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Scott L. Havsy, DO, DAApM -Board Ce
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