DOC request three complete - Cannabis Defense Coalition

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OFFENOcR 1.0. DATA:
{ ~ STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
AUTHORIZATION FOR DISCLOSURE
... '''''IVI",TION
hereby authorize the use 'or disclosure of my health information
The following individual or organization is authorized to make the disclosure:
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Purposefordisclosure:. \fe r< f>l c .. ,~.=f.·~ V\ ok dA......t1.;:(
I understand that the information in my health record may include information relating to sexually tI:Bnsmitted
infections. Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also
include information about behavioral or mental health services and treatmef1t for alcohol and drug abuse.
'This information may be disclosed to and used b
, . NAME: L
ADDRESS:~ _____________________________________
~~~--~~~~--~~~~~~~~~.
"understand that I have a right to revoke this authorization at any time, I understand that if I revoke this .'
authorization I must do so in writing and present my written revocation to the Health Information Management
Department. I understand that the revocation will not apply to information that has already been released in
response to this aut'7.ati/ Unless otherwise revoked, this authorization will expire on the following date, event,
or condition: