DOC request three complete - Cannabis Defense Coalition

STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
AUTHORIZATION fOR DISCLOSURE
OF HEALTH
OFFENDER 1.0. DATJ<
. . hereby ·authorize the use or disclosure of my health information
as described below. !he following or organization is authorized to make the disclosure:
NAME: _~C.=I B~R-,-:-"A,--·..!..le."""",Ci...E!.(.L>'-C£!.,!.L=::.(!.-' ---j''':;::S::!:V'.L'' ·_,-C~__
ADDRES& __ ~.:5~LIL/~6~--_, __ ~~~.~J21~~/~-3d-~S~,~·d~f~~L. __ ._tr~v~~~~ __
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Purpose for disclosure: ______________________________ _
I understand that the information in my health record may include information relating to sexually transmitted
infections, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also
incllJde information about behavioral or mental healtli s!7rvices and treatment for alcohol and drug abuse.
This information may be disclosed to and used by the following individual or organization:
NAME: ·iL2I:L 0 ~ :..£j Co, :dJ.J. .a :s::1-cd:..e, .
ADDRESS:' Q .. ()t;'l"t'lri{fV;+ 'd.Zhcc;ct"oo ~
1 understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization 1 must do so in writing and present my written revocation to the Health Information Management
Department I understand that the revocation wifl not apply to information that has already been released in
. response to this authorization. Unless otherwise reVoked, this authorization will expire on the following date, event,
or condition: :c-7- Q =z (if left blank, authorization will expire six (6) months from Signing).
I understand that authorizing the disclosure of this health infoimation is voluntary. I can refuse to sign this
authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the
information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure
of information carries with Itthe potential for an unauthorized redisclosure and may not be protected by federal or
state confidentiality rules. If I have questions about disclosure of my health information,l may contact the
RHIT/designee of the .
Signature
__ form Is
Social Securtty Number
'~£4r~5f;£ff-
2-7-ot
Date
(:IiiiiL-
DOC Number .
-.2-'2-07
Signature of Witness . ate
Slale iaw (RCW 70.02; RCW 70,24.105; RCW 71.05.390) and/or f,deraT reFIII/alions (42 CFRParr 2: 45 CFR 1'01'1 1(4) prohibit a.feIosur,
a/thiS in/ormarioll withoul the specific ""iltell oonsenl o/lhe person to whom itperloins. or as othenvi.e permilled by law.
DOC 13-035'(05l1912OOS) POL ' 000380.200 DOC600.02O OOC640.020 DOC670.02O LEGAL
PDU-6655-3 000055