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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
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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DoCumentation of Medical AuthoriZat
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STATE OF WASHINGTON DEPA'RTMENTOF C
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311S'E. Mission Ave Spokane, WA 992
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Page 37 and 38: j I Documentation of MedicarAuthcir
Page 39 and 40: , • J ' -1. d; z.. 00 g-' /Vo v.
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
Page 51 and 52: I I l- I I tV!. tier f!! (VLA I 4.
Page 53 and 54: ~ra.4~ OFFENOcR 1.0. DATA: { ~ STAT
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
Page 61 and 62: STATE OF WASHINGTON .DEPARTMENT OF
Page 63 and 64: T.)' ~x.. MARIJUANA MEDICINE'· 'EV
Page 65 and 66: .,.,... ..,..,.~ f~J STATE OF WASHI
Page 67 and 68: "'.... ~ . OFFENOeR 1.0. OATA: fnrt
Page 69 and 70: -----------------------_ Brown, Dam
Page 71 and 72: Nov. 26. 2008 4:37PM CBR Medical In
Page 73 and 74: No'v, 26, 2008 4:48PM CB R Me d i c
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: Prescdbar's Name (pnnt) . Prasc~jje
Page 89 and 90: I I do ncit want to ruffle feathers
Page 91 and 92: Let me know if you have questions f
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
Page 101 and 102: PRIMARY CARE PHYSICIAN AND LOOKED O
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
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Page 117 and 118: Distefano, Moriica J. (DOC) From: .
Page 119 and 120: j I Distefano, Monica J. (DOC) From
Page 121 and 122: E.... KIOSK reporting may be used i
Page 123 and 124: RE: 380 200 Community Supervision o
Page 125 and 126: RE: 380200 Community Supervision of
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Page 129 and 130: to be processed now. If this was re
Page 131 and 132: Distefano, Monica J. (DOC) From: Se
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Page 135 and 136: FW: 380200 Community Sup_ervision o
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Distefano. Monica J. (DOC) From: Di
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Nov, 26, 2008 4:39PM CBR Medical In
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Documentation of Medical Authorizat
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11/06/2008 13:05 - PAGE ./"""-1. II
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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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.Distefano, Monica J. (DOC) From: S
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~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal
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Dec.23. 2008 5:07PM ,CBR Medical In
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04/15/2009 18:28 4258696378 THCF PA
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STATEOFWASHINGTON . DEPARTMENT OF C
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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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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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MARIJUANA MEDICINE- EVAlUATtON CENT
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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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Page 3 of3 To: Checo, Ana V. (DOC),
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PageZ of3 . 253-372-6463 office 253
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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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Dec.23. 2008 4: 42PM CBR M~dical In
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D.ec.23. 2008 4:43PM CBR Medical In
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February 17, 2009 STATE OF WASHINGT
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Jan. 4. 200912:40PM CBR Medical Inc
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Jan, 4, 2009 12:41PM CBR Medical In
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Dec.30. 2008 12:20PM CBR Medical In
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