DOC request three complete - Cannabis Defense Coalition

OFFENDER I.D. DATA:
,
r
URI: OF HEALTH INfORMATION
___ , hereby authorize the use or disclosure of my health informatlpn
The. fof/owing individual or orQanization is authorized to make the disclosure: .
NAME;: -rt\- ~ .
1 J\Cl\L L~ wA q Y'+ () \
! understand that I have a right to revoke this authorization at any lime. ! understand that If I revo.ke this' authorization
I must do so in writing and present my written revocation to the Health Information Management Deparlment. I
understand that the revocation will not apply to informatiQn that has already been released in response to this
authorization. Unless otl'ierwise revoked, thIs authorization will expire on t1~e following date, event,
or .condltion: i vJN') Jl ~,-\ ~ - r0 . (if left blanK, authorization will expire six (6) .months from signing).
I understand that authorizing the disclosure of this health information is volUntary. I may refuse to sign !i:1is .
authorlzatiQn. I need not sign this form in order to ensure treatment. I understand that I may inspect or copy the .
information to- be used or disdosed, as provided in ~FR 164.524 and ReIN 70.02. I understand that any disclosure of
Information carries with it the potential for an unauthorized redisclosure and may not be protectld by, federal or state
confidentiality rules. If I have'questions about disclosure of my health information. I may contact !he
R.HIT/designee of the ..
x= 3-'/ g .. t)C{
Date ..
(Patient to complete)
~~
DOpNumber
:lIme la ... (RCflllII.OJ: RCf/' m.J~.II'j: RCW 1f.05 .. 190) GlJellDl'jerlmril'eglr{l1Iioll:l (42 erR ('/II'I 2: 45 CFR Prlrl 164) IlroMb;e (lirci()$ure
vJIhis Tlljbrmm"OIJ \lli//{UIU tire speci}lc V,1l'iCle11 corwmccJl1le persoll {Q wliam it perlllins, Drns orJri!rwf$~ pr!rmitlf!If 4'11" iGiv.
DOC tJ .. 3S ,OII2S/l00D) FOI. . . OOC JaO.2QO llOC 00D.920 DOC 540.0.0 DOC aiD.Oi!!l· LEGAl..
PDU-6655-3000083