DOC request two, part 1/5 - Cannabis Defense Coalition

iiJi'r!\.,Y'o.r 10., s,r. C'STATEOF WASHINGTONl> ~~ f DEPARTMENT OF CORRECTIONSMedicinal Use, of Marijuana Vei"ific'ationOFFENDER I,D, DATA:\,To be filled oiJt by,Prescri,ber:Dear Prescriber, .' .....By state statute the Washington State Departmentof Corrections rs charged with the responsibility to supervise some.offenders after th.ey have been convicted of a felony. The above named patient is currently under supervision by theDepartment. Supervision is designed to help the offender avoid those environments or situations that lead to their criminalbehavior. Often illicit drug use is a contributing factor in an individuaJ's criminality. Accordingly it's usual that the court orthe Department of Corrections will'impose a condition of supervision that the offender riot USe, or possess illicit drugs, .including marijuana. This offendE;lr has claimed thCit they have a condition for which the medicinal use of marijuana hasbeen prescribed. The below verification is to determine the legitimacy of their claim. Thank you hadvance for yourassistance. If you have questions please feel free to personally contact the MedicalDirector of the Department at (360)725-8700'.1. Is this patient under your care?2. Are you prescribing medical marijuana for his patient due to a diagnosis of AcquiredImmunodeficiency Syndrome (AIDS)a. If the answer to q,uestion 2 is "Yes", does he/she halle anorexia?b.lf the answer to question.2a is "Yes", does he/she have weight loss?DYesDYesDYes.D,YesDNoDNaDNaDNo3. 'Are you prescribing medical marijuana for this patient due to nausea and vomiting associated 0 Yes 0 Nowith cancer chemotherapy?.a. If the answer to question 3 is "Yes", has the patient failed to respond to'conventional DYes' 0 Noantiemetic treatments?b. If the answer to question 3a is' i'Yes", please describe what those treatments were (medication, dose,duration):' .'c. What is the planned schedule of chemotherapy?,4.While on community supervision ("parole"). the Department of Corrections only authorizes theuse of the oral synthetic formulation of marijuana. If the Department authorizes th is patient'suse of medical marijuana, will you be prescribing only the' oral synthetic formulation?. . . - .DYes,ONo5.The patient's accompanying Release of Information authorizes you to provide th~Department with current and future information related to this issue, Do you agree to notifythe Department's Medical Director of any changes in your ansWers above?DYesONoPrescriber's Name (Print)Prescriber's SignatureDate. License #: License type:Prescriber's AddressPhone Numb erDOC 14~053 (05/16/08)DOC 3BcOcG 0 0 a 5