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Prescriber's Name (Print) Prescriber's Signature 1~-'_oV Date' license #: . rYJ',D C> to D / '6 2> / I . License type: IY1 D Prescriber's Address 3// 5' C.. g'S5,'t::Jn A~I'-( Ph~ne Number SfD k-4pU!, J iiJ."'t. q '7..A' 0"2- Prescriber: please return this form and the patient's Release of Information to: --~~------------------ q--00- 5''-1 () -.!2 ,&-'8;'.b 6-6 4 ~',!J..
"'.... ~ . OFFENOeR 1.0. OATA: fnrt:' t STATE OF.wASHINGTON IJII.JLIr DEPARTMENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I, , hereby authorize the use or disclosure of ~y health information as described below. The following individual or organization Is authorized to make the disclosure: NAME: ______ ~ _______________________________ ADDRESS: _________________________________________ The type and da~e(s) of information to be used or disclosed is as follows: 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 Include information about behavioral or mental health· , .' • , • , " " . , This information may be disolosed to and used by the NAME: ______________ _ ADDRESS:· _____________ __ I understand that I have a right to revoke this authorizi authorization I must do so in writing and present my Voi Department. I understand that the revocation will not response to this authprization. Unless otherwise revo or condition: ([f I I understand that authorizing the disclosure of this hec authorization. I need not sign this form In order to ass information to be used or disclosed, as provided in CF of information carries with it the potential for an unauil state confidentiality rules. If 1 have questions about dl RHIT/deslgnee of the facility: IU,;,.~ (J h r) tfiJ nent lin ate, event, )m signing). s opythe disclosure ~deral or ~ Signature of Patient (Do not sign if fonn Is not complete) Date (Patient to complet~) Social Security Number Date of Birth DOC Numbar Signature ofWtlness Date Slale law (ReW 70.0]; RCW 711.24.105; RCW l.05.390) undid, foderal,eglliot/on. (42 CFR Pari 2; 45 CFR ParllM) prohibll disclosurc oflills inforlllallon "i/houl lit. specific written consem of the peTson 10 whom II pertains. at as olherwise pemrilled by law. OOC 1~35 (0511912008) PQL· DOC 390.2110 OOC 600.02D OOC 64D.02O OOC 670.020 LEGAL PDU-6655-3000064
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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i ( Documentation of Physician Auth
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Page 23 and 24: Or-FENDER 1.0. DATA, j' STATE OF WA
Page 25 and 26: DoCumentation of Medical AuthoriZat
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Page 33 and 34: 311S'E. Mission Ave Spokane, WA 992
Page 35 and 36: ''' .. r.~ l~} STATEOFWASHINGTON "1
Page 37 and 38: j I Documentation of MedicarAuthcir
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Page 41 and 42: Chapter 69.51 A RCW: Medical marij1
Page 43 and 44: Chapter 69.S1A RCW: Medical marijua
Page 45 and 46: Chapter 69.511). RCW: Medical111ari
Page 47 and 48: •• I ! 3115 E. Mission Ave Spok
Page 49 and 50: OFFENDER 1.0. DATA: STATE OF WASHIN
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Page 55 and 56: Prescriber's Name (Print) License#:
Page 57 and 58: 3115 E. Mission Ave Spokane, WA 992
Page 59 and 60: . ! STATE OF WASHINGTON DEPARTMENT
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Page 63 and 64: T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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Page 75 and 76: .~. :.' '. ATTEN1':tON LAW ENFORCEM
Page 77 and 78: \"'Ior"'.~ OFFENDER 1.0. DATA: I f
Page 79 and 80: Wheeler, Judine L. (DOC) From: Sent
Page 81 and 82: OMNI: Chrollos Quick Search , •
Page 83 and 84: -...... THCF MEDICAL CLINICS 1813 1
Page 85 and 86: Prescdbar's Name (pnnt) . Prasc~jje
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Page 89 and 90: I I do ncit want to ruffle feathers
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Page 93 and 94: Interpretation of Medical Marijuana
Page 95 and 96: From: Sent: To: Duggan, Brenda J. (
Page 97 and 98: NIELSEN TO COME UPSTAIRS. CCO NIELS
Page 99 and 100: Date & Tirpe Created: 12/16/2008 11
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Page 103 and 104: Distefano, Monica J; (DOC) From: Se
Page 105 and 106: 3. High Non-Violent 4. Moderate, an
Page 107 and 108: , ' ~. With Community Corrections S
Page 109 and 110: Distefano, Monica J. (DOC) From: Se
Page 111 and 112: I FW: 380200 Community Supervision
Page 113 and 114: FW: 380200 COInmunity Supervision o
Page 115 and 116: Distefano, Monica J. (DOC) · From:
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to be processed now. If this was re
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Distefano, Monica J. (DOC) From: Se
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FW: 380200 Community Supervision of
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FW: 380200 Community Sup_ervision o
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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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. I, Offender Name STATE OF WASHING
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3115 E. Mission Ave Spokane, WA 992
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Prescriber's Name (Print) License #
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OFFENDER I.D. DATA: STATE OFWASHING
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1813 Born Avenue NE, Suite'#210 Bel
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3115 E. Mission Ave . Spokane, WA 9
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3115 E. Mission Ave Spokane, WA 992
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3115 E. Mission Ave Spokcme, WA 992
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OFFENDGR I,D, DATA: STATE OF WASHIN
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.IL , Documentation of Medical Auth
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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. OA·I.o.: STATE OF WA
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MARIJUANA MEDICINE- EVAlUATtON CENT
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· I, Karen Hamilton, am a physiCia
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Distefano, Monica J. (DOC) From: Ha
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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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I Prescriber's Name (Print) License
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Living &: WeUness Centerss P.S. 371
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February 17, 2009 STATE OF WASHINGT
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Dec.30. 2008 12:20PM CBR Medical In
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