, STATE OF WASHINGTON' ,DEPARTMENT OFCORRECTIQNS,P.O. Box 41126 • Olympia, INashingto,n 98504-1129· (360) 725-8796FAX (360) 586-0252 'March 19, 2009TO:Community Corrections DivisionFROM:Karen Daniels, Assistant Secretary'-Ii " '"A, '.. r1SUBJECT:Medical Marijuana Process ChangeEffective in?nediately, <strong>DOC</strong> Fonn 14-053, Medicinal Use of Marijuana Verification, has been updated.Offenders will no longer be req~ired to fIll out this form when they have a legitimate prescription forMarinol from a licensed physician. In addition, offenders that have this prescription' will not be inviolation if they test P9sitive for THC..',' .The De<strong>part</strong>ment created a verification process for offenders to obtainappr6valforthe use of"medicaImarijuana". If an offender tells his or her CCO that they plan on using medical marijuana, Form 14-053' 'should be provided to the offender and the process explained~ As a reminder, here is the breakdown of" the approval process: '1. Upon receipt of Form 14-053, the offender and his or her medical provider have 2 weeks tocomplete'and submit it to the <strong>DOC</strong> Headquarters Physician for review. Once the Physicianrecdves the form, he will review it and make his determination within 10 days, upon which timemy office will commUnicate that decision in writing to the offender with a copy to the CCO,the CCS, and the medical provider. ,2. The offender and the medical provider will then have 15 BUSINESS days (3 yveeks) to submit a'written appeal directly to me. Once I receive the appeal, a decision will be maile'within 30business days. That decision will again be communicated in writing to the CCO, the CCS, andthe medical provider. ' ' , 'Please, remember that the offender should not receive any violations related to the use of medicinalmarijuana during this process period. Please do not hesitate to call me if you have any other questions., Tharik you., KD:mdcc:Eldon Vail, SecretaryCheryl Strange, Deputy SecretaryScott Blonien, Assistant Secretary ..Steven Hammond, Medical ,Services Director000023
"fo6'f\Bf ior s.,~ ~" . :"\tDli~"':;1: 1-i' .,.. ~':STATE OF WASHINGTON'?:~ ,~jU DEPARTMENT,OF CORRECTIONSMediCinal Use of Marijuana VerificationT~ be filled C;ut by ceo:I Pa,tient'~Name •,OF;FENDER 1.0. DATA:I :Dat~ of Birth ~I <strong>DOC</strong> NumberTo bEdilledout by Prescriber:Dear Prescriber,BystCitest?fl.He th,e Washington State De<strong>part</strong>ment of Corrections is charged with the responsibility to supelV,ise someoffenders' after they have been cpnvicted of a felony. The above named patient is currently under supervision by theDe<strong>part</strong>n,eljt;,$Lipervision is designed to help thfj .qffender~void those environments or situations that lead ~o the.ircriminalbeJlavi6i' Often illicit drug use is a contributing ·factorin an individual's criminality~ Accordingly it's ,usual that the court or .the pe.p~rtni~nt o(corrections wil! impose a condjtior cif supelVision that the offender not u$e,orpossess iIli9it drugs,includlngrnarijlJ.~~a. This offender has claimeci tha~theyh.ave a condition for which the medic:inal use of marijuana .hasbeen recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for yourassistance. If you have questions, please contact the Community Corrections Assistant Secretary at (360) 7?-5-8787.1. Is this patientlinder your care?2. Are you recommending medicalmarijuana for this patient due to a diagnosiS of AcquiredImmunodeficiency SYl1drome (AIDS)?' ''.a.b.If the answer to question 2 is "Yes·, does he/she have anorexia?_If the answer.to question 2a is "Yes·, does he/she have weight loss?,DYesDYesDYes. DYestJ NoDNoDNoDNo3. ' Are you recommending medical marijuana for this patient due-to nausea and vomiting, associated with cancer chemotherapy? ," .a. ,If the answer to question 3 is ·Yes·, has the patient failed to respond to conventional'antiemetic treatments?'DYesDYesb. If the answer to question 3a is· "Yes·, please describe what those treatments were (medication, dose,.durat!on):DNoDNo.c.·'What)s the planned schedule of chemotherapy?. . .i '4. If you answered "No· to items 2 .& 3 above, what is the reason you are recommendin'g medicinal use ofmarijuana? .a. P.lease provide evidence published in a peer-reviewed scientific publication to support the medicinaluse.ofmarijuana for this purpose.. .,, ' .5. Thepatient's'accQmpanying Release of Information authorizes you to pro'v'ide the'De<strong>part</strong>ment with current and future information related to this issue. Do you agree to notifythe De<strong>part</strong>ment's Medical Director of any char)ges in your answers above?'DYes<strong>DOC</strong> 14-053 (Rev. 3/16/09)<strong>DOC</strong> 380.200000024
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