DOC request three complete - Cannabis Defense Coalition

Prescriber's Name (Print)
License#:
Prescriber: please return th~s form and the patient's Release of Information to:
lViedical Director
Health Services DiVision
Washington State Department of Corrections
PO 80x41123
Olympia, WA 98504~21 :1.3 .
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To be filled out by DOC Physician:
. I have reviewed this verification form and find that use of medical marijuana by this patient
(check one) lOis 0 is not· .
consistent with DOC Policy.
PhYSician's Name (Print)
Instructions to DOC Physician:
Physicien'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 Liberty as a CommunityCprrections Health Record.
Date
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State law (RCW 10.02: RCW 70.2.4.105: RCW 71.05.390) and/or federal regulations (42. CFR Part 2;AS CFR Part 164) prohibit
di$t:losure 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. 7/31/08) DOC 380.200
PDU-6655-3 000052