DOC request three complete - Cannabis Defense Coalition

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Prascricer's Name (Print) ,
Medi~al Director ,
Health Services Division
Washington State Department of Corrections
POSox41123
Olympia, WA 98504-2113
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License #: Oil b a 6 Q I ¥'"3 1/ License type: _41=~D~_________
Prescribers Address '75'/ (6' E,yU,' 55:.!> /l gil p Phone N'umber SOc;· 570·';;-n-h
. Of 0;:::4 n.P' ~ct. q 1 @ '2- '
PrescrIber: please return thiS form and the ~atJent's Release of Information to: 5l.pr ;:u-!2 - 8' {P 2 'I
To be filled out by DOC Physician:
I have reviewed this verification form and find that u,se of medical marijuana by this patient
(check one) lOis 0 is not , ' ' ,
consistent with DOC Policy,
Physician's Name (Print)
Instr.Ul::t!ons to DOC Physician:
Physician's Signature
When form is complete:
1, Email your finding above to the Assistant Secretary for Community .corrections
2. File this form and the accompanying Release of Information 'in Uberty as a Community Corrections Health Record,
Date
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State law (RCW 70.02j RCW 70.24.1 OS; RCW 71,05.390) andForfederal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit
disclosure of this information without the 'specific written consent of the person to whom it pertains, or as otherwise
permitted by law. "
DOC 14-053 (Rev, 7131108)
DOC 380.200
PDU-6655-3 000048