DOC request three complete - Cannabis Defense Coalition

STATE OF WASHINGTON 

DEPARTMENT OF CORRECTIONS 

P.O. Box 411 00 · Olympia, Washington 98504-1 100 

January 15, 2010 

Mr. Ben Livingston 

Cannabis Defense Coalition 

PO Box 45622 

Seattle, WA 98145 

Dear Mr. Livingston: 

Thank you for your payment of $1.67 to cover costs associated with disclosure of 

Installment #3 ofPDU-6655 on CD. 

I have made redactions as appropriate per statute and noted them on the enclosed 

denial/appeal form. If you wish, you may appeal my denial decisions in part or whole by 

completing and mailing the appeal form to the Agency Appeals Office at PO Box 41103, 

Olympia, W A 98504-11 03. 

The enclosed records are provided in accordance with the Public Records Act; however, 

by making agency documents available to you, the Department is not responsible for your 

use of the information or for any claims or liabilities that may result from your use or 

further dissemination. 

With the transmittal of Installment #3, PDU-6655 is now complete. 

Sincerely, 

Cynthia Hood, Public Disclosure Specialist 

Public Disclosure Unit 

Department of Corrections 

clh:PDU-6655 

Enclosures 

" Working Together for SAFE Communities" 

o recycled paper


DEPARTMENT OF 

CORRECTIONS 

AGENCY DENIAL FORM / EXEMPTION LOG 

Date: 12/31/09 

Tracking Number: PDU-6655, Inst. #3 

Requestor N arne 

and Address: 

Mr. Ben Livingston 

Cannabis Defense Coalition 

PO Box 45622 


Denial of Disclosure Decided by (Name/Title): 

Cynthia Hood, Public Disclosure Specialist 

YOUR REQUEST FOR DISCLOSURE OF THE RECORDS IDENTIFIED BELOW HAS BEEN DENIED TO 

THE EXTENT AND FOR THE REASON(S) SET FORTH BELOW. 

See Exemptions Section for the explanation of the exemption(s) relied upon (numbers in the exemption 

columns below correspond to the numbers in the Exemptions Section). 

1-3,6,8, 10, 

12- 20, 22-27, 

29-32,34,43- Dependency 

47,49-51,53- 

56, 58- 62, 65- 

·68,70-75,77, 

78, 79- 81, 83, 

91- 93, 95-99, 

106, 114, 135- . 

36, 138-39, 

141-42, 144- 

46, 148-57, 

159-65, 167- 

70, 172~75, 

177, 180, 182, 

184-89,191- 

95, 197-204, 

208~10, 212- 

15,217-20, 

222-29,231- 

34,236-38, 

240-52, 254- 

59,261-268, 

270-74,276- 

95,297-311, 

313-16,318- 

21,323-26, 

328-37 339- 

19,26,31,46, 

50,55,74, 

149, 156, 169, 

222,240,251, 

258,267,271, 

294,315,328, 

332, 336, 345, 

355,363,390, 

420,432,441, 

446,451,473, 

477 

Last Updated 10/29/09 

1

RECORDS PROVIDED WITH REDACTIONS 

~~--~~~~~~~~- ---------~----------~ 

346, 348-56, 

358-64,366- 

70,373-75, 

378-83,385- 

88,390-94, 

397,400-02, 

404,406-11, 

413-17,419- 

21,423,425- 

28,430-37, 

439-42, 444- 

47,449-52, 

,454-56, 459- 

69,471-75, 

477-84,486- 

492 

15-MedicalIMenta1 

Health/Chemical 

Dependency 

/" 

;~t:\:,/; 

'9P'UlVIENt:::: 

ESORIPT~P~;;':i 

4 

Prescription 

Allen C. Alleman, DOC Offender 15-Medical/MH/CD 

M.D. 

493 

8112/08 

Prescription 

Bethany E. Rolfe, DOC Offender 15-Medical/MH/CD 

ARNP 

494 

7/12/08 

Prescription 

B. Mike Hale, DOC Offender 15-Medical/MH/CD 

M.D~ 

495 

1/22/09 ' 

Prescription 

ThomasO. DOC Offender 15-Medical/MH/CD 

Orvald, M.D. 

496 

1/26/09 

Prescription 

ThomasO. DOC Offender 15-Medical/MH/CD 

Orvald, M.D. 

497 

1/16/09 

Prescription 

ThomasO. DOC Offender 15-MedicallMH/CD 

Orvald, M.D. 

499 

9/20/08 

Prescription 

Karen Hamilton, DOC Offender 15-Medical/MH/CD 

M.D. 

Last Updated 10/29109 

2

DUPLICATE \ NON-RESPONSIVE RECORDS 

The following records, though not denied, are excluded from the responsive records for the reason set forth 

below (these records are available upon request and appropriate payment): 

DUPLICATE RECORDS 

The following pages of the responsive records are duplicate records: 

Pg(s) 498 is a duplicate of page 494 (withheld as exempt). 

Last Updated 10/29/09 3

(".- " 

~"""'":.~ 

Inr ... ~ STATEOFWASHINGTON 

~ ~ ~ DEPARTMENT OF CORRECTIONS 

M~dicinal Use of Marijuana Verification 

OFFENDER 1.0. DATA: 

To .be filled out by ceo: 

~I-..:... ____________ ----,----.,_~I ~ate of Birth· . 

____ ."1953' I_L- m _ 

. To be filled out by Prescriber: 

ber 

_ _·--,------' 

. Dear Prescriber, .. . 

By state statute the Washington State Department of Corrections 'is charged with the respol"l~ibility to supervise some 

offenders after they have been convicted of a felony. The above named patient is currently under supervision by the 

Department. Supervision is' designed to help the offender avoid those environments or situations that lead to their criminal. 

behavior. 'Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usuai"that the court or 

. the Department of Corrections will impose a condition of supervision that the offender not use, or possess illiCit drugs, 

including marijuana: This offender has claimed that they have a condition for which the medicinal use of marijuana has 

be~n prescribed. The below verification is to determine the legitimacy of their claim. Thank you iri advance for your 

assistance. If you.have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. . 

1. Is·this patient under.your care . flI Yes 

2. Are you prescribing medical marijuana for his patient due to a diagnosis of Acquired 

Immunodeficiency Syndrome (AID~) . . 

DYes 

a. If the answer to questipn 2 is "Yes", does he/she have ano~exia DYes 

b. If the answer to qu~stion 2a is "Yes", does he/she have weight loss DYes 

3. Are you prescribing medical marijuana fo'r this patient du~ t9 nausea and vomiting. associated 

wit~ cancer chemotherapy . 

DYes 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional. 

DYes 

antiemetic treatments . . 

. . 

b. If the answer to question 3a is,"Yes·, please describe what those treatments were (medication, dose, 

dur~tion): " .. 

DNo 

'~,NO 

DNo 

DNo 

I5·NQ 

DNo 

c. What is the planned schedule of chemotherapy! 

4. While on community supervision ("parole") the Departrnent of Corrections only authori~es the 

use of the oral synthetic formulation of marijuana. If the Department authorizes this patient's' 

·use of medical marijuana, will yol.! be prescribing only the oral synthetic formulation 

DYes 

~No 

5. The patient's accompanying Release of Information authorizes you to provide the 

Department with current and future information related to this issue. Do you agree to notify 

the Department's Medical Director of any changes in your answers above 

AllenC.Al1emanMD ~" '" . 

3461611 PI. So.,Ste 4 . .' 

----=Pr-e-sc-.rib;-e-.r's-N"a-m-e...... Widij=· =raI:-t"tW:~ay,"",""'WXi'fA~~'Hi8~OIAO~3--. 

~ 

License#: / S- -) '/ , . Lice~e type: 

--~~-~-~~----~ 

~es 

DNo 

ill . ---/- 0. g' 

Date 

Prescriber's Address . Phone Number " 53

Prescriber: please retur~ .this form ;and the patient's R$lease of In!ormation to: 

Medical Director 

. Health Services Division 

Washington State' Department of Corrections 

PO Box 41.123 

OlYmpia, WA98504-2113 

To be filled out by DOC P~ysician: 

I have reviewed this verificationJonn and find that use of medical marijuana by this.patient 

. . (check one) lOis· D is not . '. • . 

consistent with. DOC Policy. ,. 

Physician's Name (Print) 

Physician's S!gnature 

Date 

Instructions to DOC. Physician: 

. When form is complete: 

1. Email your finding above to the Assistant Secretary for Comm.unity Corrections 

2. . File 'this form and the accompanying Release of Information in Uberty as a Community Correc.tions Health Record. 

J 

State law (RCW 70. 02; RCW 70.24.1 05; RCW 71.05.390) andlor federal regulations (42 CFR Part 2; 45 CFRPart 164) prohibit disclosure of 

. . this information without the specific written consent of the person io whom it pertains, or as otherwise permitted by law. . 

~ . 

DOC '14-053 (05/16/08) 

DOC 380.200 

"'-PDU-6655-3 000002

i 

( 

Documentation of Physician Authorization to Engage in the 

Medical Use of Marijuana in Washington state 

Dat~.....-... 

Bi~~ 

I am a physician licensed in the State of Washington. I have diagnosed the above named 

patient as having a terminal or debilitating medical condition as defined in RCW 

69.51A.010. '. 

I have advised the above named patient about the potential risks and benefits of the 

medical use of marijuana. I have assessed the above named patienfs medical history and 

. medical condition. It is my medi I opinio that this patient may benefit from the medical 

use of marijuana. 

/ D. -·(-'0 g 

Signature of 

PhYSician. __ ~ __ ~~~~~~~~~~ ______ ~ ____________________ 

Printed Name of fI \ l' . Allen C. Alleman MD 

Physician'-_-=-"--L-.!.-!.J...l.l,....t.-L..-t....t1"'-'~e~fYY'Ar\~!....!-___ ~341ofl6~16:t-11!+1 Pl So., Ste 4 

Federal Way, WA 98003 

Rlf;ks and benefits of medical marijuana 

Under Washington state law, the use of medical marijuana is now permissible for be 

patients with terminal or debilitating medical conditions; The law regulating this (RCW . 

69.51A) allows physicians to advise patients about the risks andbenefrt:s of the medical 

. use of marijuana. 

The medical and SCientific evidence supporting the use of medical marijuana remains 

controversial in the medical communil;y. Not all health care providers believe that medical 

marijuana. il> safe or effective and some providers feel that it is a c!angerous drug. 

According to the Washington state law, the medical use of marijuana may benefit patients . 

diagnosed with ·the foDowing medical conditions: cancer, human immunodeficiency virus 

(HIV), multiple sclerosis, epilepsy or other seizure or spasticity disorders; some types of 

intractable pain; glaucoma, either acute or chronic; Crahn's disease; hepatitis C with 

debHitating nausea or intractabie pain; or diseases, including ano!"e)!ja, which result in 

nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, Of. 

spasticity .. 

Some of the risks of medical marijuana may include possible long-term effects on the 

brain in the areas of memory, coordination and cognition; impairment of the ability to drive 

or operate heavy machinery; respiratory damage; possible lung cancer; and physical or 

psychological dependence. 

This form provided by the Washington State Medical Association 7/2007 

I4JJe..L: o! J, ~ ~

7500123300 P.O 1/0.1 

-r~.. 

TRANSACTION RE~RT 

OCT/06/2008/.MON 04:38 'PM 

MEMORY 

OK 

SG3 


DEPARTMENTOF CORRECTIONS 

Pierce County Community justice Center 

ceo Lynne Hudson .. 

1016 South 28th Street .' 

. Tacoma, WA98409 

253-680-2683 (work)· 

253-597-4352 (fax). 

Date: C"p~: Co "2 , CJi> . 

To: . DA· ~>W::"ts 

Resppnse: 

'. ") 

\IU~b~r of page$ inoluding this page@>..-. ........_---'-_ 

=rom: Ly~ne Hudson, CC03. Ta.coma, WA ~8409 . 

rhis facsmile may contain conf1d~ntial information inte.nded for the Individual or ~ntry to whom it is addressed .. 

)0 not read, copy or disseminate this info rmation unless. you"are the addressee or the person responsible for 

leliverina it: "If vou receive this communication an error of ease call me. Lvnne Hudson; at 253-680-2683. " 

PDU-6655-3 000005

OCT/ Oct. B. LUO~, 11: ::J9AM T ~co tt l. Havsy, UU, .U·AA~MF.AX· No. 1253597("""O:::.~ .. No. 1L1~ ~. L 

. UO/'::UUO/lYlVI~ u'*:jf fro ac.!J,...-..."l • ./ 

. . / 

P. uu, 

/"'''''- . 

~. ~. 

• ~l STATE OF WASHINGTON 

II lUI'. DfPAR1'M!NTOFeORRECTIONS 

Me~lelnal Use of MarfJuana Verification 

Dear Prescriber... '. .' 

. By state statute the Washington State Department of Corrections is charged with the responsibility to supervise some. 

offenders after they have been eonvlct~ Of' a f~lony. The above named .. patient il currently under supervision by the 

Department Supervision is delalgned to help the offender aVQid those environments or.sltuaUons that lead to their criminal 

behavior. Often illicit drug use Is a confribu,ting fac!or in an individual's criminality. Accordingly !tiS usual that the court or 

·the Departmen~ of CorrectIons wllllmpo.se a tondrtlon of supervision that the offender not ulle, or possess Dlicit drugs, . 

r including marijuana. This offender has claimed· that tl1ey have a. condition for which the m$dlelnal use of marijuana has 

been recommended. The below verification is to determine !he legitimacy of their claim. Thank you. il) advance for your 

assIstance. If you have questions please. fee! free to pemonally tomact the Medical Director of the Department at (360) 

725-8700: . . . .... . . . . 

. . ~ 

'1. Is this patient under YD':!r care . 

2. 

Are you recommending medical marijuana for his patient due to a diagnosis of Acqujred 

.. Immunodeficiency Syndrome (AIOS) . . . . 

B. 

b. 

If the answer to question 2ls "Yes·, does he/she have anorexia 

if the answer. to quest/on 2a Is "Yes~, dQeshe/she have weight loss 

3 ...·Ara you recommending medical marijuana for this patient due to nausea "and vomiting 

.as~ociated with cancer chemotherapy . . 

4. 

a.. 

If' the answer to qfJestion 3 Is "Yes·, has the patient failed to respond to conventlonel 

antiemetic Iraatmente 

DVes 

DVes ONo 

DYes DNO 

DYes ~ 

DYes 

b. .If the answer to question Sa is 'Yes--, please describe what those treatments were (medicatlon. dos~, .. 

duration): 

DNa' 

~ What~~,~neJi:W~~=IJIJt-~ .~~ 

If you ans/;f;;;.NO" to It~£ 2 8. 3 above, what,is the reason you are recommendIng medicinal use Of .. 

marijUa~ " .'. 'I-~ . ~~. /1.~c- 12,/1. . . fiJ~ 

j}tYl It- 1 ~ ~~v') : 

•. Please Pro,1de sv'

OCTiLVu~t'VVtlO/liL~,U~4I, ~hj~~ Ta~p-S ~. 'Havsy, [}V, lIA~rl~AX No. i253597r'l 

NO, ILlll r, j 

p, UUj 

• ',I 

license type:. 

.~oate 

Prescriber's Address 

. 'Pho!'16 Number. 

. prescrIber. please returnt~l. form ,and the patient's Release af Informat!0n to: 

Medical Olrector 

Health Servloes Division' 

Washington State Department of CorrectionS 

PO BoX 41123 

Olympia, WA eSS04-2113 

To be fined out by DOC Phy.slclan: 

" 

I Iiave reviewed U,is, verification 'form $nc! find that' use of medical marijUana by this ,patient 

" (check Dne) lOis CJ I. not " ....' 

consj~ht \¥ith DOC Policy. " . 

jShYCldanl~ NIU1I11 (l'rtnt) . 

P"yslclan's Slgnscure 

InstNc~ions to DOC ~hysician: 

When form Is complete: . , 

1.' ErnaR yourtindi!1g above ~ the Assistant seCretary for Community Corrections 

2. ,File this forrn iJnd the acccmpan~~g ~lease of Jnform~tio.n in LiJj~ as a Community Co~ons Health Record. 

" 

'. 

. Slate law (RCW 70.02; RCW 1Q.24.10$; RCW 11.05.390) andfDr Mder.ll regulatiDIIS (42. CFR Pllrt 2; 4S CPR Part 164) pf"CIhibit 

. . disdDSU~ oftIJis infonnan wf\hout the speclft~ wrfHan consent of ilia parsDft 10 wIIcrn ft ptrtalnl, or as atherwlsa 

pennltted bylaw. . 

COC 14-05:3 (Rev. 7/31/08) 

DocaeO,20a 

PDU~6655-3 000007

, ( .....,-.\ 

') 

',. . ~'. 

;' 

'-UVing c$ Wellr)es~: ,Centers, P.S. 

3716 Pacific'Avenue, Suite IE 

Tacoma,:WA 98418 

P~one: (253). 473~2SS3 

F=ix: (2'53) 473-0545 

;.... 

':'. 

DOCUMENT,A TION of MEDiCAL AUTHO,RIZA TION. to POS$E~S,;~ARIJUANA, ,..:" , 

, , for MEDICAL PURPOSES i:~,'t~E STATE, ofWASHING1l,$N " , ,,",_ .... 

; Y j( ;: 

oj 

Date of 8 

I, Scott L. Havsy, DO, am an o'steopath'i'c ~liysici~n"licel1~eo in the, Stat.e' ,of W~§hington. 'I am treati~g 

:the above-named patient for a terminal illness or a debilitating condition as defined in RCW 

69.51A.010. I have' adyised the above-named patient about the potential ris'ks arid benefits oObe , 

medical i:!se of marijuana. I have asse~sed thE;l$bove-named patient's medical history and m'edicat 

conditi9n: It is in ll!¥ medical opin.ion that the potential be ,its of the medical us'e of marijuana would 

, " , (~kely,outvveig'h the fiealth ", KS for thi~ p.~tient. . \ ' 

SiS. natu re of. Phys ician: ~~:t7---""-=--¥-+--'-.!i+--:-\-'E::i6---i:-- 

.. '. 

" Today's Date: '~' / ~ 0"0 l' ' :, f:, E~piration Da~~: -~f---T---=tr-~-..." 

.. T\ Risks and benefits,of medical, marijuana: 

to •• 

Under Washington State Law, the use of medical marijuana is noY" permissible for som~ 'p~tients with 

, ,termir]al or debilitating ifll1esses. The faw regu(ci:ti'ng this (RCW 69.51.A) allo'i¥s physicia'ns to advise 

'p'atients apouUhe ,r!!S'ks and, beriefits regarding the medical use of marijuana.' " 

, ','I, " 

The me,dical and scientific eVipe!1ce according to the use' o~ medical marijuana remainE; controyersial ' 

in the'medical community, Not,all hea(thcare prDviders believe that med.ical marijuana is safe,or , 

effective and some"providers feel that it is a dangerous dr.ug. , ," , 

.,'. ': t;,·:. :::::-:".;:.' ...... :., ... ': .... ·\ .. ·~r·~:'.'!f.r ~t~'!~ :"'!\1.~'" •.. : .... j .... :.r:: ..... "7"~. 

According to the VV!ashington,Sta,te Law the benefits of medical mariJuan~, m~y include treating 

,n~usea and vomiting from chernotherapy; AIDS wasting syndrome;'sE1vere muscle spasms for 

,multiple sc!ero~is or other spasticty disorders; gl'aucoma; and some types of intraCtable pain 

unrelieved by standard medical treatments and! medications, ' 

Some of the ri~ks of medical rriarijua~a ,may inelude possible long-term effects of the brain, in the 

areas of memory, coordination, cognitiqn;impa'irment,of the' aqility to drive or qpera~e 'heavy" 

'machinelY; respiratory damage; possible IUhg cancer;' and physic;al or psychol.ogical dependence:' 

. . ". '. .' . 

',- , 

\ 

PDU-6655-3 000008

Distefano, Monica J. (DOC) 

From: 

Sent: 

To: 

Subject: 

Attachments: 

Hudson, Lyr:me A. (DOC) 

Thursday, April 16, 2009 3:37 PM 

Distefano, Monica J. (DOC) . 

Medical MJ discovery packet 

CC000001.TIF 

~ 

CCOOOOO1.TIF (194 

KB) . 

1 

I. 

PDU-6655-3000009

... ""'"'''' 

f~ STATEOFWA$HINGTON 

~ aEPARTMENT OF CORRECTIONS 

Medicinal, Use, of Marijuana Verification 

OFFENDER 1.0. DATA; 

To be filled 'out by Prescriber: 

Dear Prescriber, .. 

By state statute the Washington State Department of Corrections is charged with the responsibility to supervise some 


Department. Supervision is·deslgned to help the offender avoid fhose environments or situations that lead to their criminal 

behavior. Often Illicit drug use is a contributing factor in an individual's' criminaiity. AcCordingly it's usual that the court or' 

the Department of Corrections will impose a cc:mdition of supervision that the offender not use, or possess illicit drugs, 

including marijuana. This offender has claimed that they have a condition for. which the' medicinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you.!n advance' for ypur 

assistance. If you f:lave questions pleas~ fe,el free to personally cOf.ltact the Medical Dtrector 'of the' Department at (aBO) 

725-8700. " , 

1. Is this patient under your cace 

2. Are you recommending medical marij'uana for his patient due to a diagnosis of Acquire,d ' 

Immunodeficiency Syndrome (AlPS) 

a. If the answer to question 21s "Yes·, does he/she have anorexia 

b. If,the answer to question 2a Is "Yes", does helshe have weight.loss 

0Ves 

oVes. 

DVes 

OV~IS 

ONo 

.GfNo' 

DNo 

oNo 

3. Are you recommending medical marijuana for this palient due to nausea and,vomitlng 

associated with cancer chemotherapy . 

'a. If the answer to q'uesHon,3 is "Yes", has the patient failed to respond to conventional 

antiemetic treatments! ' , ' 

DYes 

Dyes 

b. 'If the answer to question 3a Is "Ves"; 'please describe what those treatme~ts were (medication, dose, 

duration): 

aNo 

DNo 

c. What is the planned schedule of chemotherapy 

4. If you .answered"No· to items 2 & 3 above" what is ilie reason you are recommending medicinal use of 

marijuana· ' , 

throV'-k,. ~\,\V"-,' 

a. Please provide evidence'published in a peer-reviewed scientific publication to support the medicinal use of 

marijuana for thfs purpose .' 

5. While on community supervision ("parole") the Department of Corrections only authorizes the 

use, of the oral synthetic formulation of marijuana. If the D,epartme nt authorizes th is patient's. ,DYes 

use of medical marljuana, will you be prescribing only the oral synthetiC formulation' 

. .. . .' 

ErNo 

6. The patient's accompanying Relea!!e of Information authorizes you to provide the ' 

, Department with current and future information'related to this issue. Do youagrae to notify '0 Yes [Q-No 


DOC 14-053' (Rev. 7131/08) 

DDe3S0.200 

PDU-6655-3 000010

Prescriber's Name (Print) 

Presorl~r's SIgnature 

3-:'1-01 

Date 

License #: 

License type: 

, ' '\3,\/:\", $~(et..~; '~Jt1.@v" • c{.!; It e yytCHI\P\.;j(.JY' 

Prescriber's Address J Phone Number 

Prescriber: please return this form and the pat/ent's Release of Information to: 

Medical DireCtor 

Health Services Division 

Washington State Department of Corrections 

PO Box 41123 

Olympia, WA Q8504-2113 

To be, filled out by DOC' Physician: 

I have reviewed this verification form and find that use of macncal marijuana by this patient 

, (check one)' lOis 0 is not ' , . 

consistent with DOC Polley. 

Physicia,n's Name (Prlnt) 

Physlclan's Signature 

Date 

,lnstr-uctiq,gEl.to,oqc Ph~sicl~: 

When form Is complete: 

1. Email your finding above to the Assistant ,Secretary for Cominun'lly 90rrections 

2. File this form and ~e accompanyihg Release of Information, In Uberty as a Community Corr~ctlons Health Record. ' 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andfor fedaral regulatfons (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure ofthls Information without the specific written consent of the person to whom It pertaIns, or as othernlse . 

permitted by law. 

DOC 14-053 (Rev. 7/31/08) DOC 380.200 

PDU-6655-3000011



P.o. Box 411 00 • Olympia, Washington 98504·11 Oil 

March26,2009 

,Bremerton, WA 98310 

DearMl: •• 

, Your Medicinal ,Use of Marijuana request Was received on March 18 i 2009. Uponrevlew by the, 

Deparlment of Corrections' Health. Services physician, your request has been denied. 

You may appeal this decision by s~ding your written request within 15 business days, on or before 

Apri117.2009. Please send your .request to the address below: ' 

Karen Daniels, Assistant Secretary 

Community Con-eclions Division 


P.O. Box. 41126 

Olympia, WA 98504·1126 

, ' 

Your request must provide additional information that wa~ not included with your original request. 

Appeals that do not contain new information will be denied. You 'Will receive a response to your 

appeal requeSt witlrin30 days of receipt. 

Karen Daniels, Assistant Secretaly 

, Community Corrections Division 

KD:md , 

00: Miabael Isoo, Community Corrections Supelvisor 

Lee Cecil, Community Cor.i:ections Officer 

, . 'Field File -_ . . , 

II Working Together for SAFE CommunftleS" 

PDU-6655-3000012

Distefano. Monica J. (DOC) 

From: 

Sent: 

To: 

Subject: 

Ison, Michael S. (DOC) 

Tuesday, March 31, 2009 3:02 PM 

Cec~, 

FVVlllllllllllllllpdf 

Attachments: 

Is he going to appeal 

Michael S. Ison 

, : Community Correqtions Supervisor 

Kitsap Peninsula 

5002 Kitsap VVay, Lower Level 

Bremerton, VVA 98312 

360-415-5645 . 

From: Distefano, Monica J. (DOC) 

Sent: Tuesday, March 31, 2009 2:53 PM 

To: Ison,~ecil, Lee Ann M. (DOC) 

Subject:.__._pdf . 

, Please see the attached denial of medical marijuana for •••• DOC _ 

A hardcopy will follow. 

~KB) 

" 

Thank you! 

Monica Distefano 

Executive Assistant to 


Community Corrections Division 

7345 Linders'onWay,SW 

Tumwater, WA 98501 MS: 41126 

(360) 725-8796 

mjdistefano@doc1.wa.gov 

1 

PDU-6655-3 000013


From: 

Sent: 

To: 

Subject: 

Ison, Michael S. (DOC) 

Wednesday, April 01, 20092:17 PM 

Ceci~ 

FW:lllllllllllllllpdf 

If he does, no violations for mj until after the appeal 


Community Corrections Supervisor 


5002 Kitsap Way, Lower Level 

Bremerton, WA 98312 

360-415-5645 

From: Cecil, Lee Ann M. (DOC) 

Se.nt: Wednesday, April 01, 2009 6:22 AM 

To: Ison, 

Subject: RE: 

pdf 

I'm not sure. This is the first I've heard of it. I'm guessing he will. He is to report· today: So, I'll ask him 

From: 

Sent: 

To: 

Subject: 

Is he going to appeal 


Community Cqrrections Supervisor 


5002 Kitsap Way, Lower Level 


360"415-5645 


Sent: Tuesday, March 31, 2009 2:53 PM 

To: Ison, ~ecil, Lee Ann M. (DOC) 

Subject:lllllllllllllllpdf . 

Please see the attached denial of medical marijuana for_· D~C_ 

A hardcopywill follow. 

« 

Thank you! 

. Monica Distefano 



Community Corrections Division . 

7345 Linderson Way $W 


(360) 725-8796 . 

1 

PDU-6655-3000014

"Page 1 ofl" 


From: 

Sent:" 

To:" 

Melissa leg gee [melissa@cbrmedical.com] 

Tuesday, February 17, 2009 12:16 PM 

Murphy, Jillian L. (DOC) 

You probably got this via fax yesterday, l:Jutjust making sure you got it: Please forward this to monica. 

Sincerely, 

Melissa Leggee 

Clinic Director . 

CBR. Medical, Inc 

Spokane 509-242-8624 Fax 509-340-2710 

Seattle 206-774-6493 Fax 206-418-6659 

Tri-Cities 509-416-2267 Fax 509-340-2710 

Vancouver 360-635-6464 Fax 206-418-6659 

No virus found in this outgoing message. 

Checked by AVG. 

:Version: 7.5.5521 Virus Database: 270.10.25/1957 - Release Date: 2/17/2009 7:07 AM 

5/13/2009 

" i 

PDU-6655-3000015

eRR Medical, Il1c 

3115 E. Mission Ave 

Spokane, WA 99202 

mJs.StJ....c€2 C6g li.ed'c4..-/ .. C!-Dr I 1 .. 

d ,..;- I it -',:2 00 9 

o Urgent o For Review CI Please Comment o IPlellise Reply o Please Rec.ycle 

·1 i 

I 

I ! 

1 

! . 

CBR Medical, Inc. - 3115 E. Mission Ave, Spokane, Wa 99202 

Seattle Pilone 206-774-6493 FCllx 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-41 8-6659 

CONFIDENTIALITY NOTICE: This communication is intended for. the sale use of the individual and 

entity to whom it is addressed, and Illay contain infonnation that is privileged, or confidential and 

exempt from. disclosure under applicable law. You are hereby notified that any dissemination, 

distribution, or duplication of this communication by someone other than the. intended addressee or its 

designated agent is strictly prohibited. 

Alllnformatioll is Protected Under U.S. Federal Law 

PDU-6655-3 000016

~\ 

I 



P.o. Box 411'00· Olympia, Washington 98504·1100 

January 26,2009 

DearMr_ 

Your Medicinal Use of Marijuana request was received on Januaty 8, 2009. Uponreview·bythe 

Department of Correcti9ns' Health Services physician, your request haS been denied. 

You may appeal this decision by sending your written request within 15 busine~s days of this letter, 

which is on or before February 16, 2009. Pleas~ send your request to the address below: 

Karen Daniels; Assistant Secretary 

Community COlTections Division 

Department of Con'ections 

P.O. Box 41126 

O~ympia, WA 98504-1126 

Your request must proVide additionai information that was not included' with your original request. 

. Appeals that do not contain new information will be denied. You will receive a response to your 

appeal request within 30 days of receipt . . 

'. Sin 1f'ety, 


Conununity Correc:tions Division 

KD:md . . 

cc: Jack Brucick, Community Corrections ,Supervisor 

Douglas Holland, Community Corrections Officer 

Field File 

Physicianis Office: 

Attn: Melissa Leggee 

CBRMedical 

3115 E. Mission Ave. 

Spokane, WA 9920~ 

}' Working Together for SAFE Communities" 

PDU-6655-3 000017

Fax 

: ' 

3115,E. Mission Ave 

Spokane, WA .99202 

[J Urgent [J For Review ' [J Please Comment 0 Please Reply [J 1Pl

OFFENDER 1.0. DATk 



AUTHORIZATION FOR DISCLOSURE 

OF 

I 

i 

I ,. 

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i 

: 

:. 

. : 

Purpose for disclosure: Co mliJ , {, 'g r'7 C « 

I understand that the information in my health record may include information relating to sexuaily transmitted 

infections, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also 

include information about behavioral or mental health services and treatment for alcohol and drug abuse. 

This information may be disclosed to and used by the following individual or orgaJlif:ation: 

. NAME: ttkg h,',yt" '3ftd < Dp-r '" {2 U (f'e c. L J VI. .s 

ADDRES& __________________ ~------------------ 

I understand that f have a right to revoke this authorization at any time. I underst;;jnd that if I revoke this 

authorization I must do so in writing and present my written revocation to the Health Information Management 

Department. I understand that the revocation will.not apply to information that has already been released in . 

response to this authorizatiOjl' Unless otherwise revoked, this authorization will expire on the following dat~, event, 

or condition: ,,:6 ('1 f-O

Or-FENDER 1.0. DATA, 

j' 

STATE OF WASHiNGTON 


Medicinal Use of Marijuana Verification 

Dear Prescriber, 


offenders after they have been convicted of a felony. The above named patient is currently under supervision by the, ' 

Department Supervision is designed to help the offender avoid those environments or situations that lead to their crimina! 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will impose a'condition of supervision that the offender not use, or possess illicit drugs, 

including marijuana. This offender has claimed tIJat they have a condition for which the med,ieina! use of marijuana has 

been recommended. The bel,ow verification is to determine the legitimacy of their claim. Thank you in advance for your 

. assistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. ' ' ./ 

1· 

- , 

1, Is this patient under your care ~s 0 No 

,., 

2. Are you recommending medical marijuana for his patient due to a diagnosis of ACquired 

Immunodeficiency Syndrome (AIDS) 

DYes ~ 

a, If the answer to question 2 is "Yes", does he/she have anorexia E1'I'es -UNo 

b. If the answer to question 2a.is "Yes", does he/she have weight loss ' D'H!S ' DNa 

3,' Are you recommending medical marijuana for this patient due to nausea and vomiting 

associated with cancer chemotherapy 

DYes ~ 

a. ' If the answer to question 3 is "Yes", has the patient failed to respond to conventionai 

antiemetic treatments 

G·~1'e5 ElI'ttJ 

b. if the answer to question 3a is ~es", please describe what those treatments were (medication, dose, 

duration): ' , tv' j/\ . 

4. 

c, 

a, 

What is the planned schedule of chemotry:rapy 

" N/~" 

If you answered "No' to items 2 & 3 above, what is the r~ason you are 'recommending medicinal ure :";Tf, 

marijuana '. S e,e... '-- (.\~ .. _:.:.'- . N ... \

License #: 

,Prescriber's Address 

License type: 

Phone Number 

Prescriber: please return this,form and the patient's Release of Information to: 

Medical DirElctor 


Washington State Department of ,corrections ' 

PO Box 41123 

Olympia, WA 9B504·2113 ' 

.( 

~ 

i 

I 

To be filled out by, DOC Physician:' ' 

I have reviewed this verification form and find that use of medical marijuana by this patient 

, (check one) lOis 0 is ncit ' , 

consistent with DOC ,PoliCY. 


Instructions to DOC Physici,an: 

Physician's Signature 

Wren form is complete: 

1. Email your finding above to the Assistant Secretary for Community Corrections 

2. File' this form and the accompanying Release of Information in Liberty as a Community Corrections Health. Record. 

Date 

I 

I. 

,/ 

i 

1 ,. 

! 

i 

State law (RCW 70.02; RCW 7Q,24,105; RCW 71.05.390) andforfederal regulations (42. CFR Part 2;.45 CFR Part 164t prohibit 

disclOsure of this information without the llpeclfic written consent of the person·to whom it pertains, or as otherwise 

pennitted by law. 

DOC 14-053 (Rev. 7/31/08) 

006380.200 

PDU-6655-3000021

DoCumentation of Medical AuthoriZation to Possess Marijuana 

for Medical Purposes In Washington State 

PATIENT NAME: __ _ 

DATEOFBIRTH:~ 

Ii-;;;;;~~~~~~;;;t;;;;;;;;::-;;;-;;:" :am;.::a~~~;;;iCIa~· n licensed in the Sbat& ofW8sblngton 

'" ness debilitating condition as defined by 

anti benefits of the m8diosI use 

. icel hiStory and medical condition. 

ical use of marijuana may outweigh 

i 

I 

1 

I 

! 

[ 

r 

~ 

i 

I 

Physician Nama:_--=~-9I====--r+-_ 

Physician Signature:_+-__ ~f--___ -I-_ 

This recommendation 

Date:_---:O~5I03J2==OO::;:8:;...... __ 

Risks and benef1t8 of medical marij na 

Under Washington law, the u Of medioal aJ'ijuana is "CHI permissible fOr some patients 

with terminal or debiDtating iU • 'I1l9. reglJlating this (RCW 89.S1A) allows physicians . 

to advise patients about the ri 

oUhe me6lcal use of marijuana. 

The medical and scientific 

.'ng the use d medical man]uana remains 

controversial in the medical munity. aU health care providers believe flat medical 

marijuana is safe or effective nd so I'Q\Iiders fQel that It Is a dangerous drug. 

According to 1he Wash Sta the benefits of,medlcal marijuana may include 

treating nausea and vomitin from otherapy, AIDS wasting syndrome, severe muscle· 

spasms from multiple scIe . or spasticity d'1SOf'deIS. glaucOma, and some types of 

irrtraatable pain. . , 

Some of the risks of I marijuana may Include possible long-term Bft'ects Of1he brain in 

the areas of memory, coordination and cognition; Impairment of the ability to drive or opecate 

heavy machinery; respiratoIy damage; possi.bIe lung ~ncer; and physical or'psychological , 

dependence. 

Recommendation 

As this patienfs'''60 day supply", as stipulated by RCW 69.51A(2)(b}, I recommend 24 ounces' 

of dried. Cl.lred marijuana and as many plants as the patient feels necessary to maintain this ~80 

day supply". 

RavIMd TJ07 

, 

l 

r 

I 

.\ 

I 

I 

1 

I 

i 

1 

I 

I 

I 

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! 

. ! i 

PDU-6655-3000022

Page 10f1 


From: Melissa le9gee [melissa@cbrmedicaLcom] 

. Sent: Tuesday, February 17, 2009 12:.57 PM 

To.: 


Subject: 

DOC Apeal 

Attachments: 200902161 

. Sincerely, 

Melissa L~ggee 

Clinic Director 

CBR Medical, Inc 

Spokane 509-242-8624 . Fax. 509-340-2710 

Seattle 206-774-~493 Fax 206-418-6659 

Tri-Cities 509-416-2267 Fax 509-340-2710 

Vancouver 360-635-6464 Fax 206-418-6659 

. No virus found in this outgoing message. 

Checked by AVG .. 

Version: 7.5.5521 Vrrus Database: 270.10.25/1957 - Release Date: 2117/2009 7:07 AM 

\/' 

5/13/2009 

PDU-6655-3 000023

'.!, 

To: 

C!6R MedicaO,. h'IlC 

31)5 E. Mission Ave 

Spok""ne, WA 99202 . 

I l 

I 

I 

i 

; 

i 

i. 

CBR Medical, loe. - 3115 E. ~:.2 Aw, Spoka"" Wa "202 cfJ. 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tn-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTICE: This communication is intended for the. sole Lise .of the individual and 

. entity to' whom it is addressed, and may contain information that is privileged, or. confidential and 

exempt from disclosure under applicable law. You are hereby notified that any' dissemination, 

distribution, or duplication of this communication by someone other than the intended addressee or its 

designated agentis strictly prohibited. . 

! 

I·' 

I 

I 

1 

All Information is Protected Under U.S. Federal Law 

PDU-6655-3 000024



P.o. Box 41100· Olympia, Washington 98504~1100 


. OCt;lan Park, WA 98640 

Dear Mr._ 

Your Medicinal Use of Marijuana request was received on January 14, 2009. Upon review by the 

Department of Corrections' Health Services physician, your request has been denied. 

You may appeal this decision by sending your written request within 15 business days of this letter, 

which is on or before February 16, 2009. Please send your request to the address below: 



.Department of Corrections ' 

P.O. Box 41126 . 

Olympia, WA 98504-1126 

Your request must provide additional information that was not included with your original request. 

Appeals that do not contain new information will be denied. You will receive a response to your 

appeal request within 30 days of receipt. 

I i 

'j 

i j, 

I 

! 

j' 

Sin~cJelY" . . 

'. 

~Danio '. AWtant S"","", 

Community Corrections Divi~ion 

.'~ 

KD:md 

cc: David Phillips, Community Corrections Supervisor 

Linda Tolliver, Community Corrections Officer, 

Field File 

Physician's Office: 


CBRMedical 


Spokane,WA 99202 

" Working Together for SAFE Communities"· 

I 

. I 

I l 

-G n:cyclcd poper 

PDU-6655-3 000025


DEPA'RTMENTOF CORRECTIONS 


OF HEALTH INFORMATION 

Or-FENDER I.D. DATA: 

hereby authorize the use or disclosure of my health information 

The following individual or organization is authorized to make the disClosure: 

NAME: 'C;BiR A1e.d(~C4j .;£1'1 C· . 

ADDRESS -::> / J ~ - nA - , 1 . JL L 

: .J h C:, /Vlf .-S $l.d ,1 a:Ve. 

The type and date(s) of information to be used or discloSed is as follows: 

V f' ~. r~ '-;;;~J' 11; .. 

U S~ =~ R~ "0& =1: : /~ tlj(;i7;fi:;-fd;] 

5---{·qrTe _ . . . U . 

-{ r. C.." I OVl t ..p . (U C "'L- ( I . 'I q 1/1 "L-: 

Purpose for disclosure: V.e ~:f';' C et-r.'on 0 f' f.e "\.:

I. 

I 





To be filled out by Prescriber:· 


By state statute the Washington Stale Departmel')t of Corrections is charged with ·the responsibility to supervise some 

offenders after they have been convicted of a felony. The above named patient is currently under supervisioD by the 

Department. Supervision is designed to'help the offender avoid those environments or situations that lead to their criminal 

behavior. Often iHicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, 

including marijuana. This offender has claimed that they have a condition for which the med[cinal use of marijuana has 

been recommended.' The below verification is to determine the legitimacy of their claim. Thank you in advance for your 

assistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. . 

1. Is this patient under your care 

2. Are you recommending medical marijuana for his patient due to a diagnosis of· Acquired 


a. If the answer to question 2 is "Ves", does helshe have anorexia 

If the answer to question 2a is ·"Ves", does helshe have weight loss 

b~ 

,.~Yes 

Dyes 

DYes 

DYes 

DNo 

,t1No 

'DNo 

DNo· 

3. Are you recommending medical marijuana fortbls patient dueto nausea and vomiting 

associated with cancer ch.emotherapy 

DYes 

~NO 

a. [f ~he answer to question 3 is "Yes", has the patient failed to respond to conventional D Ves . D No 


b. If the answer to question 3a is "Yes·, please describe what those treatments were (medication, dose, 

duration): 


4. 

. If you answered "No· to items 2 & 3 ab,ove, what is tlJe reasqn you are recommending medicinal use Jf . /._ /. 

marijuana .. C//-{j"v/ c.

.' .or", g u:,Se J f 'D. G4A() ~~ 

Prescriber s Name (Print) • Prescriber's Signature 

License #: M 0 L06 Gz (p q ~i..; License type: ~ALJ.-..l..I2~ ________ _ 

Prescriber's Address .3) /~.) C, .dI,':$ S j' i) t1 I/- V ~ Phone· Number 

. Spo Ka ru;> , W 4. '7 e:U ... tJ 2- 

Prescriber: please return this form and the patient's Release of Information to: 




PO BoX41123 

. Olympia, WA 98504-2113 

D'7 - 670~;z. f' (. 

769.';(1-/;;1.' g. b2 ~ 

To be filled out by DOC Physician: 


(checK one) lOis 0 is not' .... . . . . 

consistent with DOC PQlfcy. 


Physician's Slg~ature 

Date 

Instructions to DOC Physician: 

When form is complete: 


2. File this form and the accompanying Re!ease of Information in Uberty as a Community Corrections Health Record. 

State law (Rew 70.02; RCW 70.24.105; ROW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this information without the specific written consent of the person 'to whom it pertains, or as otherwise 

pennit;ted by law. 

DOC 14·053 (Rev. 7/31108) 

. DOC 380.200 

PDU-6655-3 000028

Documentation of Medical Authorization to Possess Marijuana 

for Medical Purposes in Washington State 

PATIENT NAME: __ ___ 

DATEOFBIRTH:~ 

I, Dr. Russell D. Glynn , am a physician licensed in the State of Washington 

and I am treating the above patient for a'terminal illness or a debilitating condition as defined by 

. RCW 69.51A.010... . 

I have advised the above named patient about the potential risks and benefits of the medical use 

of marijuana, t have assessed· the above named patient's medical history and medical condition. 

It is my medical opinion that the potential benefits of the medical use of'marijuana may outweigh 

the health risks for this patient. . ( 

. Physician Name: __::.D""r 

..:.R;;:u:,::;s::,;se::;:,I:...:1 

D::.;.:...;G:::.I~y:.::nn.:.· ___ WA License Number;, __.;,;.M;,,::D..;,6..::,O..:.,06..;,6.;,;.9.;,;.4_4 

. . ~ >P""'" _._.~---l__'-·""· 

Physician Signature:,' ~-

311S'E. Mission Ave 


_~~Q.....~=!/....,~:""",;,~~,,"=__ 

l)...:..a __ te; ., _ j''-{ __ 0_°...,;-1:-__ 

Pages: 

eel 

o Urgent .. 0 For Review 0 Pleas~ COlninent 0 IPlease Reply 0 Please Recycde 

·Comments: 

CBR Medical, Inc. - 3115 E, Mission Ave, Spokane, Wa 99202 

tie Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri-Cities Phone 509-416-2267 Fax 509-340"2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTiCE: This commlJnication is intended for the sole use of the' individual and . 

entity to whom it is. addressed, and may contain information that is· privileged, or confidential and . 

exempt from disclosure under applicable law, You are hereby notified that any dissemination, 

distlibution, or duplication of this communication by someone other than the intended addressee 01' its 


AlIlnformatiol1 is Protected Under U.S. Federal Law 

, 

'! 

PDU-6655-3 000030




OF HEALTH Ihlr:r)~~IA 


, hereby authorize the use or disclosure of my health information 

indiividW'lI.or organization is authorized to make the disclosure: 

NAME: -----"C~B!...LtC.-"----=d~'A~tlWL:J!o.,. .L-··...k· 

~.=_(_' _,.--_ 

ADDRESS: __ ~:S~iLI_S:~~~~~~~~_'-L~~(~'~S~~~;~I~'b~~L __ ~~~v/~e ___ 

5P t'ai/l(J i tL)&t. 7' 1207 

Purpose for disclosure: ~ Y I' - F'l '. j . ~.;...' -f ,'. 

I~qql +0 (A'S(f' poSS""~.s c

''' .. r.~ 

l~} STATEOFWASHINGTON 

"1.JIiUL,- DEPARTMENT OF CORRECTIONS . 

Medici~al Use of Marijuana Verification 

OFFGNDER 1.0. DATA: 

To be fillE1d out by Prescriber: 




Department Supervision is designed to help the offender avoid those environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly ifs usual that the court or 

the Department of Corrections will impose a .condition of supervision that the offender not use, or possess illicit drugs, 

including marijuana. This Offender has claimed that they have.a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your 

assistance. If you have questions please feel free to personally contact the Medical-Director of the Department at (360) 

725-8700. .'. '"/ . 

1, . Is .this patient under yourcare ' . ~s D No 

2. Are you recommending medical marijuana for his patient due to a diagnosis of AcqUired 


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 

3. Are you recommending' me'dlcal marijuana for this patient due to nausea and vomiting 


DYes 

r;pr-es 

. D4'e! 

DYes 

CI blo 

blNo 

a, If the answer to question 3 is 'Yes", has the patlent failed to respond to conventional ~_ 0 No 

antiemetic treatments . 

b. If the answer to question 3a is "Yes", please descr"ibe what those trea.tments were (medication, dose, 

duration): . . N ~ .{'::\ p~::ue.\\: '. 

4. 

c.' What is the planned schedule ofchemotherapy 

. . N,~ r~i'pp'\-::V:~ \~ 

If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use 9 f 

marijuana '. . S e.\!.' c. ~c-,-~;: ~ ...... C\:~:"t /VI:,~ r, 

I 

5 .. 

a. Please proV;de evidence published in a peer-reviewed SCientific publication to support the medicinal use of 

marijuana for this purpose . ' .. ,::>.... '\ "f-\;.'\~~'V!'" .' 

.s~ ~ e n- c.. '- N. c 

While on community supervision ("parole") the Department of Corrections o~ly aut~oriz~s t~e 

use of the oral synthetic formulation of marijuana. If the Department ~ut~onzes ~hls patients. 

. use of medical marijuana, will'you be prescribing only the oral synthetiC formulation 

0 Yes 

6. 

The patient's accompanying Release of Information authorizes you to provid~ the . . 



DYes 

DOC 14·053 (Rev. 7/31/08) 

OOC3eO.200 

I .. 

PDU-6655-3 000032


LI'cense #. '("f-.O "'''''~ . P\- . 

. ense type: \ p

j 

I 

Documentation of MedicarAuthcirization to Possess Marijuana 


PATIENT NAME: __ ----' 

OATEOFBIRTH:~ 

I, Antoine Johnson , am a physician licensed in the State of Washington 

and I am treating the above patient for a terminal illness or a debilitating condition as defined by 

RCW 69.51A.010. ' 

I 'have advised the above named patient about the potential ri'sks and benefits of the medical lIs'e 

of marijuana. I have assessed the above mimed patient's medical history arid medical condition. 

It is my medical opinion that the pote~C\1 benefits of the medical use of marijuana may outweigh 

the health risks for this patient. ~l ' 

Physician Name: Dr. AntoinehJhnson WA License Number: 'MD00039048 

, / I 

I 1 

Physician Signature: ' I /i Date: 01/11/2009 

I / ' 

This recommendation expire~/on: ~06/2009 

Risks and benefits of medical mari./(Jf3na " , , ' 

Under Washington law, the use tff medical marijuana is now permiss'ible for some patients 

with terminal or debilitating iIInesse~,. The law regulating this (RCW 69 . .51 A) allows physicians 

to ,advise pati,ents about the risks a . benefits of the medical use of marijuana. ' : 

" The medical and scientific evide e supporting the use of medical marijuana remains . 

controversial in the medical commu ity. Not all health care providers beHeve that medical 

marijuana is safe or effective and some providers feel that it is a dangerous drug. 

According to the Washington State l;3.w the benefits 'of medical marijuana may include 

treating nausea and vomiting from chemotherapy, AIDS wasting syndrome, severe muscle 

spasms from multiple sclerosis or other spasticity disorders, glaucoma, and some types of 

intractable pain. . 

. Some of the risks of medical marijuana may include possible long-term effects of, the brain in 

the areas of memory, coordination and cognition; impairment of the ability to drive or operate 

heavy machinery; respiratory damage; possible lung cancer; and physical or psychological 

dependence, 

' 


As this patient's "60 Day Supply", as stipulated by RGW 69.51A.040 (3)(b) and 

WAC 246.75-010, this Qualifying Patient can reasonably expect to have in their Posession and 

Need a total of no more than 24 Ounces of "Useable Marijuana" and no more than 15 Plants. 

CBR Medical, InC. . . 

Administrative Office 

3115 E. Mission Ave, Spokane, WA 99202 

Spokane: 509-242-8624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418-6659 

EMERGENCY OR LAW ENFORCEMENT ONLY 

CALL 509-570-2886 OR 509-570-6943 

PDU-6655-3 000034

~I 

CIBR Medican, 'me 



Phone:, 

Pages: 

Re: 

. 0 U ..... I~.eview 0 PI_ •• eo ....... o Please Reply o Please Recycle 

·Comments: 

Q,.n'·c\ 

~tC1,"d:"j fI1l j,GLI ~'dua",-" 

Ir\ WosklljfD0 sfdP ~~ 

CBR Med1",', ,,,. - 3115 E. MO.'" A,e,'::Z!!: 99202 


Tri-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENT1ALITY NOTICE: This communication is intended for the sole use of the individual and 

entity to whom it is addressed, and may contain information that is privileged, or confidential and 

exempt from disclosure under applicable law. You are hereby hotified that any dissemination, 

distribution, or duplication of this communication by someone other than the intended ad

, • J ' -1. d; z.. 00 g-' 

/Vo v. tf( '. 

',eh:apte~ 

246-75 WAC, 

MEDICAL MlUt!:JtJ.2Wi\. 

NEW SECTION 

, WAC 245-'1S-0iO Msdiaal marijuana. (1) Purpose.' The purpose 

of ~hi~ section is to define,the amount of marijuana a qual~fying 

pat~ent' could r'easonably expect to need over a sixty-day period for 

their personal medical usa. It is intended to: ' 

(a) , Allow medical practitioners to' exercise' their best 

pro~essional judgment in the delivery of medical t:featment; 

, (bj Allow designated,' providers to ass~~st patients in the, 

manner ,provided in chap-ter 69,51A RCWt and ' 

(oj Provide clarification to. patients, law enforcement and 

others in the use, of medical marijuana,', 

(2) Definitions. 

, " (a) "Designated provider" means a person as defined in RCW 

69,. 51A. 010., ' , ' 

(bj "Plant," means any ,marijuana ,plant in any stage o.f growth. 

(c) "Qualifying patient" means a person: as defined in RCW 

69,'SlA.010. 

' 

(c1:) , "Useal:ile marijuana" means the dried leayes and flowers of 

the 'Cannabis plant family Moraceae,. 'Useable: marijuana excludes 

sterns, stalks" seeds and roots. ' " 

(3) E'xesuI!iptive sixty-day supply. , 

(a) A qual;Lfying patient: and a designated provider may POSSBSS 

a total of no more than twenty-four ounces of useable marijuana, 

and, no more ,than fifteen 'plants', , 

(b) Amounts listed in (a) of this subsection are total. am~unts 

or mar,ij,uana between both a qualifying patient and a designated 

provider-. 

(e) The pre;sumption in this sec,!:ion may b'e overcome with 

ev.idence of a qualifying patient's necessary med~cal use. 

OTS-,1732.3 

PDU-6655-3 000036

. Chapter 69.51 A RCW: Medical marijuana 

Page 1 of6 

Chapter 69.51A RCW 

Medical marijuana 

Qhspjl;lr.J,i;;Jing 

RCW Sections 

Q.!U5Jb,Q.Ql Purpose and intent. . 

fiQ.§1A.010 Definitions. 

11.$. •. ;;1A.020 Construction of chapter. 

9.9..51A.030 Physicians excepted from state's criminal laws. 

R.e.,§JA..040 Failure to seize marijuana, qualifying patients' affirmative defense. 

f.a.§.1A.050 Medical marijuana, lawful possession - State not liable. 

[!2,~lAJLQq Crimes - Limitations of chapter. 

Q~ ... q1.A..070 Addition of medical conditions. 

§.e .• g.tA.080 Adoption of rules by the department of health -- Sixty-day supply for qualifying patients. 

pj!.51.A~Q 

Short title ~ 1999 c 2 •. 

69.51A.901 Severability - 1999 c 2. 

~e,!;i.1A.902 Captions not law - 1999 c 2. 

69.S1A.()()S 

urpose and Intent. 

The people of Washington state find that some patients with terminal or debilitating illnesses, under their physician's 

care, may benefit from the medical use of marijuana. Some of the illnesses for which marijuana appears to be beneficial 

incluile chemotherapy-related nausea and vomiting In cancer patients; AIDS wasting syndrome; severe muscle spasms 

associated with multiple sclerosis and other spasticity disorders; epilepsy; acute or chronic glaucoma; and some forms of 


. The people find that humanitarian compassion necessitates that the decision to authorize Ihe medical use of 

man luana by patients with terminal or debilitating illnesses Is a personal, individual deciSion, based upon their physician's 

professional medical judgment and discretion. 

Therefore, the people of the state of Washington i\'ltend that 

Qualifying patients with termina! or debilitating illnesses who, in the judgment of their physicians, may benefit from the 

medical use of marijuana, shan not be found guilty of a crime under state law for their possession and limited 'use of 

marijuana; . 

Persons who act as designated providers to such patients shall also not be found guilty of a crime under state law for 

assisting with the medical use of marijuana; and 

Physicians also be excepted from liability and prosecution for the authorization of marijuana use to qualifying patients 

for whom, in the physician's professional judgment, medical marijuana may prove beneficial. 

[2007 c 371 § 2; 1999 c 2 § 2 (InlliaUve Measure No. 692, approved November 3; 1998).) 

. Notes: 

Intent·- 2007 c 371: "The legislature intends to clarify the law on medical marijuana so that the lawful use of this 

substance is not impaired and medical practitioners are able 10 exercise their best professional judgment in the 

delivery of medlc!!1 treatment, qualifying patients may fully participate in the medical use of marijuana, and deslgnatfild 

providers may assist patients in·lhe manner provided by lhis act without fear of slate criminal prosecutIon. This act is 

also intended to provide clarification to law enforcement and to all participants In lhe judicial system." [2007 c 311 § 1.] 

htlp:llapps.leg. wa.gov/RCW Idefault.aspxCite=.69.S1A&full=true 5/8/2008 

PDU-6655-3 000037

Chapter 69.51 A RCW: Medical marij1.1ana 

Page 2 of6 

69.51A.010 

, Definitions. 

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. 

'(i) "Designated provider" means a person who: 

(a) Is eighteen years of age Dr older; 

(b) Has been designated in writing by a patient to serve as a designated provider under this chapter; 

(c) 15 prohibited fi:om consuming marijuana obtained for the personal, medical use of the patient for whom the 

indivIdual is acting as designated provider; and 

(d) 15 the designated provider to only one patient at anyone time. ' 

(2) "Medical Use of marijuana" means the production, possession, or administration of marijuana, as defined in RCW 

69,50.101 (q), for the exclusive benefit of a qualifying patient in the treatment of his or her terminal or debilitating illness. 

(3) "Qualifying patient" means a person who: 

" (a) Is a patient of a physician licensed under chapter 18.71 or 18.57 RCW; 

(b) Has been diagnosed by that physician as having a terminal or debilitating medical condition; 

(c) Is a resident of the state ofWashlngt6n at the time of such diagnosis; 

(d) Has been advised by that physician about the risks and benefits of the medical use of marijuana; and 

(e) Has been advised by that phYSician that they may benefit from the medical use of marijuana. 

(4) "Terminal or debilitating medical condition" means: 

(a) Cancer, human immunodeficiency virus (HIV), multiple sclerosis, epilepsy or other seizure disorder, or spasticity 

disorders; or 

(b) Intradable pain, 'limited fqr tj1e purpose of this chapter to mean pain unrelieved by standard medical treatments 

,and medications; or 

(c) Glaucoma, either acute or chroniC, limited for the purpose of this chapter to mean increased intraocular pressure 

unrelieved by standard treatments and medications; Dr 

(d) Grahn's disease with debilitating symptoms, unrelieved by standard treatments or medications;'or 

(e) Hepatifis C with debilitating nausea or intractable pain unrelieved by standard treatments or medications; or 

(f) Diseases, including anorexia, which result in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle 

sp.asms, or spasticity, when these symptoms are unrelieVed by standard treatments or medications; or 

(g) Any other medical condition duly approved by the Washington state medical quality assurance commission in 

consultation with the' board of osteopathic medicine and surgery as directed in this chapter. 

(5) 'Valid documentation" means: 

(a) A statement signed by a qualifying patient's physician, or a copy of the qualifying patient's pertinent medical 

records, which states that, In the physician's professional opinion, the patient may benefit from the medical use of 

marijuana; 

(b) Proof of identity such as a Washington state drive~s license or identicard, as defined in RCW 46.20.035; and 

(c) A copy of the physician statement described in (a) of this subsection shall have the same force and effect as the 

,I 

http://apps.leg.wa.gov/RCW/defaultaspxCite=69.51A&fuJ1=true 5/8/2008 

PDU-6655-3 000038

Chapter 69.51 A RCW: Medical,marijuana 

,Page 301'6 

signed original. 

[20070371 § 3; 1~9~ c 2 § 6 (Initiative Measure No. 692, approved November 3, 1998).] 

Notes: 

Intent •• 2007 c 371: See note folfowing RCW ~1A.OOli. 

69.51A.020 

Construction of chapter. 

Nothing in this chapter shall be construed to supersede Washington state law prohibiting the acquisition, possession, 

manufacture, sale, or use of marijuana for nonmedical purposes. 

[199902 § 3,(initiative Measure No. 692, approved November 3, 1998).] 

69.S1A.03Q 

Physicians excepted from state's criminal laws. 

A phYSician licensed under chapter 18.71 or 18.57 RCW shall be excepted from the state's criminal laws and shall'not be 

penalized in any manner. or denied any right or privilege. for. 

(1') Advising a qualifying patient about the risks and benefits of medical use of marijuana or that the qualifying patient 

may benefit from the medical use of marijuana Where such use Is within a professional standard of care or in the 

individual physician's medical judgment; or " 

(2) Providing a qualifying patl!>nt with valid documentation, based upon the physician's assessment of the qualifying 

patient's medical history and current medical condition, that the medical 'use of marijuana may benefit a particular 

qualifying patient. , ' , 

[2007 0371'§4; 1999 02 §4 (initiative Measure No. 692. approved Novembet3.1998).] 

Notes: 

Intent - 2007 c 371: See note flIowing RCW 69,!jIA,P,QQ. 

69.51A.040 

Failure to seize marijuana, qualifying patients'affirmative defense. 

(1} If a law enforcement officer determines that marijuana Is being possessed lawfully under the medical marijuana law. 

the officer may document the amount of marijuana, take a representative sample that is large enough to test, but not 

seize the marijuana. A law enforcement officer or agency shall not be held civ1l1y liable for failure to seize marijuana in 

this circumstance. 

' 

(2) If charged with a violation of state law relating to marijuana, any qualifying patient who is engaged In the medical 

use of marijuana, or any designated provider who assists a qualifying patient in the medical use of marijuana, will be 

deemed to have established an affirmative defense to such charges by proof of his or her compliance with the 

requirements provided in this chapter. Any person meeting the requirements appropriate to his or her status under this, 

chapter shall be considered to have engageq in activities permitted by this chapter and shall not be penalized In any , 

manner, or denied any right or privilege, for such actions. 

(3) A qualifying patlent, if eighteen years of age or older, or a designated provider shall: 

http://apps.leg.wa.govIRCW/default.aspxCite=69.51A&fu\\=true 5/8/2008" 

PDU-6655-3 00,0039

Chapter 69.S1A RCW: Medical marijuana 

Page 4 of6 

(al Meet all criteria for status as a qualifying patient or designated provider; 

i 

I 

I i, 

i 

I ' 

I' 

(b) Possess no more marijuana than is necessary for the patient's personal, medical use, not exceeding the amount 

necessary for a sixty-day supply; and 

(0) Present his or her valid documentation to any' law enforcement official who questions the patient or provider 

regarding his or her medical use of marijuana. . 

(4) A qualifying patient, if under eighteen years of age at the time he or she is alleged to have committed the offerise, 

shall demonstrate compliance with subsection (3)(a) and (e) of this section. However, any possession under subsection ' 

(3)(b) ofthis section"as well as ,any production, acquisition, and decision as to dosage and frequency of use, shall be the 

responsibility of the parent or legal'guardian of the qualifying patient. 

[2007 c 371 § 5; 1999 c 2 § 5 (Inltlatlve Measure No. 692, approved November 3, 1998).} 

Notes: 

Intent - 2007 c 371: See note following RCW g9.51A.005, 

69.S1A.OSO 

Medical marijuana, lawful possession - 

State not Iiable~ 

(1) The lawful possession or manufacture of medical marijuana as ,autliorized by this chapter shall not resUlt in the 

forfeiture or seizure, of any property. 

(2) No person shall be prosecuted for constructive possession, conspiracy, or any other criminal offense solely for 

being in the presence or vicinity of medical marijuana or its use as authorlz~d by this chapler, 

(3) The state shall nol be held liable for any deleterious outcomes from the medical use of marijuana by any qualifying 

patient. 

. [1999 c 2 § 7 (Initiative Measure No. 692. approved November 3, 1998).} 

69.S1A.060 

Crimes ;..... Limitations of chapter. 

(1) It shall be a misdemeanor to use or display medical marijuana in a manner or place which is open to the view of the 

general public. ' . 

(2) Nothing in this chapter requires any health insurance provider to be liable for a'ny claim for reimbursement for the 

medical use of marijuana. ", 

(3j Nothing in Ihis chapter requires any physician to authorize the use of medical. marijuana for a 'palient. 

(4) Nothing In this chapter requires any accommodation of anyon-site medical use of mariJuana in any place of 

employment, in any school bus or on any school grounds, in any,youth center, In any correctional faCility, or smoking, 

medical marijuana in any public piece as thet term Is defined in RCW 70.160.020. " 

(5) It Is a class C felony to fraudulently produce any record purporting to be, or tamper with the content of any record 

for the purpose of having It accepted as, valid documentation under ·RCW 69.51A.QtQ(6)(a). 

(6) No pe~on shall be entitled to claim the affirmative defense provided in RCW 69;51.A,.Q4Q. for engaging in the 

medical use of marijuana In a way that endangers the health or well-baing of any person through the use of a motorized 

vehicle on a street, road, or highway. 

http://apps.leg.wa.govfR.CW/default.aspxCite=69.51A&full=tlUe 5/812008 

PDU-6655-3000040

Chapter 69.51A RCW: Medical marijal1a 

Pa~e 5 of6 

[2007 c 371 § 6; 1999 c 2 § 6 (Initiative Measure No. 692, approved November 3, 1998).J 

Notes: , 

*Reviser's note: The reference to RCW Q.$.&1A.010(6)(a) is elToneous. RCW 69.,q-'A.ll.iQ(5)(a) was apparently 

intended. " 

I 

I 

I 

. Intent - 2007 c 371: See note following RCW 69.51A.QQ~. 

------,~,-----------------.--,.=----,----,--~~------.---------------- 

69.51A.07D 

Addition of medical conditions. 

The Washington state medica! quality assurance commission in consultation with the board of ost~pathic medicIne and 

surgery, or other appropriate agency as designated by the govemor, shaff accept for consideration petitions submitted to 

add temninal or debilitating conditions to those included in this chapter. In considering such petitions, the Washington 

state medical quality assurance commission in consultation with the board of osteopathic medicine and surgery shall 

include public notice of, and an opportunity to comment in a public hearing upon, su'ch petitions. The Washington state 

medical quality assurance commission in consultation with the board of osteopathic medicine and surgery shall, after ' 

hearing, approve or deny such petltlo'ns within one hundred eighty days of submission. The approval or denial of such a 

petition shall be considered a fin'al agency action, subject to judicial review. 

'. 

12007 c 371 § 7; 1999 c 2 § 9 (Initiative Measure No. 692, ,approved November 3, 1998).J, 

Notes: 

Intent - 2007 c 371: See note foffowlng RCW li~"pjb.QQ§. 

"all d.= 

69.51A.080 

Adoption of rules by the department of health - 

Sixty.day su pply for qualifying patients. 

(1) By July 1, 2008, the department of health shall adopt rules defining the quantity of marijuana that could'reasonably be 

presumed to be a siXty-day supply for qualifying patients; this presumption may be overcome with evidence of a ' , 

qualifying patient's necessary meqical use. 

, (2) As used in this chapter, "sixty-day supply" means that amount of marijuana that qualifying patients would 

reasonably be expected to need over a pertod of sixty days for their persona! medical use. During the rule-making 

process, the department shall make a good faith effort to include all stakeholders identified in the rule-making analysis, as 

being impacted by the rule. ' 

(;3) The department of health shall g~ther information from medical and scientific literature, consulting with experts 

and the public, Elnd reviewing the best practices of other states regarding access to an adequate, safe, consistent, and 

secure source, including alternativ.e distribution systems, of medical marijuana for qualifying patients. The department 

shall report its findings to the legislature by July 1, 2008. 

[2007 c 371 § 8.J 

Notes: 

Intent •• 2007 c 371: See note following RCW q9.51A.005. 

69.S1A.900 

Short title -1999 c 2. 

This chapter may be k,~own and cited as the Washington state medical use of marijuana act. 

; 

! 

I 

http://apps.leg.wa.govIRCW/default.aspxCite=69.51A&full=true 5/8/2008 

PDU-6655-3 000041

Chapter 69.511). RCW: Medical111arijuana 

Page 6 of6 

[1999 c 2. § 1 (Initiative Measure No. 692. approved November 3. 1998).J 

·S9.51A.901 

Severability - 1999 c 2. 

If any provision of this act or its application to any person or circumstance is held invalid. the remainder of the act or the 

application of the provision to other persons or circumstances is not affected. . 

[1999 c 2. § 10 (I~iliative Measure No. 692. approved November 3. 1998).) 

l" _t 

69.51A.91l2 

Captions not law-1999 c 2. 

Captions used in this chapter are not any part of the. law: 

[1999 c 2. § 11 (Initiative Measure No. 692. approved t'/0vember3. 1998)'J 

" . " 

http://appsJeg.wa.gov/RCW/defauit.aspxCite=69.51 A&full=true 5/8/2008 

PDU-6655-3" 000042

(. 

Page 1 of1 

Distefano; Monica J. (DOC) 

From: Melissa leggee [melissa@cbrmedicaLcom] 

Sent: Tuesday, February 17, 200912:57 PM· 

To: 


Subject: 

Attachments: 20090216161 

Sincerely, 




Spokane 509-242-8624 Fax 509-340-2710 

Seattle 206-774-6493· Fax 206-418-6659 

Tri-Cities 509-416-2267 Fax 509-340-2710 

Vancouver 360-635-6464 Fax 206-418-6659 


Checked by AVG. . 

Version: 7.5.552/ Virus Database: 270.10.25/1957 - Release Date: 2/17/2009 7 :07 AM 

5/1312009 

PDU-6655-3 000043

•• 

I 

! 



I , 

o IPUease Reply 

0 Please Recycle 

.' .Com~"ts.!€J ! l _ '~ 

~"- JL~~' 

. tI'Ja ~J~j}Jw~ 

~~0ff' brc . 

(' Vf'r: M1 Y :'y(),' h 

. -iyw'r ~ ~J'Y/ I 1 « 

J;PP 

. . CBR.Medical, Inc. - 3115 E. Mission Ave, Spokane, Wa 99202 


Tri-Cities Phone 509-416-2267 Fax 509:340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTICE: This communication is intended for the sole use of the individual and 

. entity to whom it is addressed, and may contain' information that Is privileged, oT con~denjjal and 

exempt from disclosure under applicable law. You are hereby notlfied that any dissemination, 


designated agent is strictly prohibited. . 

i 

I 

f· 

I 

f 

I. 

I 

I 

All Info rn;ation is Protected U.nder U.S. Federal Law 

PDU-6655-3000044


DEPARTMENT Of CORRECTIONS 

P.o. Box 41100' Olympia, Washington 98504·1100 


I. 

I 

I 

Seattle, W A 98118 

. Dear l\1r._ 

Y9ur Medicinal Use of Marijuana request was received on January 14,2009. Upon review by the 

Department of Corrections' Health Services physician, your reques~ has been denied. 

. . 





'Department of Correcti~ns 

P.O. Box 41126 

Olympia, WA 98504-1126 

" 

Your request must previde additionalinfonnation that was not included with your original request 


appeal request within 30 days of receipt. . / 

Sinp~ ~. C) 

~~v§/ 

. tare:r0E>aniels, Assistant Secretary 

Community COl1'ections Division 

KD:md 

cc: Misi Nimese Liulamaga, Community CorrectionsSuperyisor . 

Erin O'Donnell, Community Correction::; Officer 

Field File 



CBR Medical 

3H5 E. Mission Ave. 


.. 


PDU-6655-3 000045




AUTHORIZATION FOR DISCL,OSURE 


following individual or organization is authorized to make the disclosure: . 

NAME: CJ3 R L=1ed>ctJ;..f .;in C 

ADDRESS: .3 /15" e. ,11/1/;5$,,1 a Av'e. 

. !' (RCW 70.02: RGW70.24.10S: RCW 71.05.390) andlorftderol regttlations (42 CF'RPart2; 'IS CFR Part 1(4) prohibirdL!C/o5UI" 

, a/thiS in/ormation without th. specific ",UWl CO/1sent oflhe person to whom it pertains, or as athenYise permitted by law. 

DOC 13-0lS (0511912008) POL DDC380.200 DOC 600.020 DOC 640,020 DOC G7O,020 

LEGAL 

./ 

I 

i. 

i 

I 

I i, 

, 

r 

r 

PDU-6655-3 000046

1 

I 

,fI'PflorS.t!1I' 

~~ ~ '. 

l J STATE OF WASHINGTON 

. DEPARTMENT OF CORRECTIONS 


OFFENOER'1.D, DATA: 

To be filled out by Prescriber: 


By'state statute the Washington State Department of Corrections is charged with the responsibility to supervise some' 

, offenders after they have been convicted of a felony. The above named patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead to their criminal 

bej1avior. Often illicit drug use is a contributing factor in an individual's criminality. Accon;lingly it's usual that the court or 


including marijuana. This offender has claimed that they have a condition for which the medicinal use of mariJuana has 


assistance. if you have questions please feel free to personally contact the Medical Director of the Department at (360} 

725-8700. ' ~ 

1. is this patient under your care ify es D No 

2. 

3. 

4. 

Are you recommending medical marijuana for his patient due to a,diagnosis of Acquired 


a. If the answer to que,stion 2 is "Yes", does hefshe have anorexia 

b. If the answer to question 2a is "Yes", does hefshe have\r~eight loss 

Are you recommending medical marijuana for this patient due to nausea and vomiting 

, associated with cancer' chemotherapy ' 

Dyes 

DYes 

DYes 

DYes 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional DYes 


b. , ff the answer to question 3a 

r 

is "Yes", please de,scribe what those tf·eatments were (medication, dose, 

duration): 

f ~ 

c. 

What is the pianned schedule of chemotherapy 

'pl'V ' 

' •. ..'. 

.,' 

If yo_~ answered UNo" to items 2 & 3 above, wl1at is the'reason you are recon~mendingcTediCinat use of 

maruuana , . ' . c:f2.:c.. A--t -f-e--e...~,. . 

~ 

,~, 

,ErNo 

'~' 

[{No 

I , 

!. 

I 

i 

5. 

6. 

~. 

Please provide evidence published in a peer-reviewed scientific publication to support the' medicinal use of 

marijuana for this purpose , '.' _ 0., ' 

, 'J-e..~~'~~ 

While on community supervision ("parole") the Department of Corrections only authorizes the 

use of the oral synthetic formulation of marijuana. If the Department ~uthorizes ~~is patient's 

use of medical marijuana, will you be prescrfbing only, the ,oral synthetiC ~Qrmulabon 

The patient's ac~ompanying Release of Information authorizes you to pr~vide the . ' 

Department with current and'future information related to this issue. Do you agree to notify 


DOC 14-053 (Rev, 7/31/(8) 

DYes 

DYes 


PDU-6655-3000047

I 

I 

l- 

I 

I 

tV!. tier f!! (VLA I 4. S: 'J 

Prascricer's Name (Print) , 

Medi~al Director , 



POSox41123 

Olympia, WA 98504-2113 

"~I ~ Ie;" 

-1t-I~ 

License #: Oil b a 6 Q I ¥'"3 1/ License type: _41=~D~_________ 

Prescribers Address '75'/ (6' E,yU,' 55:.!> /l gil p Phone N'umber SOc;· 570·';;-n-h 

. Of 0;:::4 n.P' ~ct. q 1 @ '2- ' 

PrescrIber: please return thiS form and the ~atJent's Release of Information to: 5l.pr ;:u-!2 - 8' {P 2 'I 


I have reviewed this verification form and find that u,se of medical marijuana by this patient 

(check one) lOis 0 is not , ' ' , 

consistent with DOC Policy, 


Instr.Ul::t!ons to DOC Physician: 



1, Email your finding above to the Assistant Secretary for Community .corrections 

2. File this form and the accompanying Release of Information 'in Uberty as a Community Corrections Health Record, 

Date 

1 

i 

1 ' 

f. 

I 

, ! 

i 

I 

State law (RCW 70.02j RCW 70.24.1 OS; RCW 71,05.390) andForfederal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this information without the 'specific written consent of the person to whom it pertains, or as otherwise 

permitted by law. " 

DOC 14-053 (Rev, 7131108) 


PDU-6655-3 000048


. for Medical Purposes in Washington State 

PATIENT NAME: __ _ DATE OF BIRTH: _1978 

I. . Dr. Mohammad H. Said • am a physician licensed in the State of Washington 

arid I am treating the above P!'ltient for 8 terminal illness or a debilitating condition as defined by 

RCW 69.51A.010. . 

r. have advised the above 1")8fTled patient aboUt the potential risks' and benefits of the medical use 

of marijuana. I have assessed the above named patient's medical history and medical condition. 

It is my medical opinion that the potential benefits of the medical use of marijuana may outweigh 

the health risks for this patient. . 

· Physician Name: Dr. Mohammad H. Said 71'1Se Number: MD00018311 

Rhysician Signature: 

This recommendation expires on: 12/05/2009 

/Gt. It ~ cu. J Date: 02107/2009 

----~~~~------ 

· Risks and benefits of medical marijuana 

Under Washington law, the use of medical marijuana is now permissible for some patients 

with terminal or debilitating illnesses. The law regulating this (RCW 69.51A) allows physicians 

to advise patientS about the risks and benefits of the medical use of marijuana. . 

The medical and scientific evidence supporting the use of medical marijuana remains 

controversiai in the medical community. Not all health care providers believe that medical 

· marijuana is safe or effective and some providers feel that it is a dangerous drug. 

According to the Washington State law the benefits of medical marijuana may include 


spasms from multiple sclerosis or other.spasticity disorders, glaucoma, and some types of 

intractable pain. 

Some of the risks of medical marijuana may include possible long-term effects of the' brain in 

the areas f rtiemory, coordination and cognition; impairment of the ability to drive or operate 


dependence. . 

·Recommendation 

As this patient's "60 Day Supply'!, as stipulated by RCW 69.51A.040 (3)(b) and 

WAC 246-75-010, this Qualifying Patient can reasonably expect to have in their Posession and. 

Need a total of no more than 24 Ou('!ces of "Useab.le Marijuana" and no more than 15 Plants. 

CBR Medical, Inc. 


3115 E. Mission Ave, Spokane, WA99202 

Spokane: 509-242-8624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418-6659 


CALL 509-570-2886 OR 509-670-6943 

PDU-6655-3 000049

~ra.4~ 

OFFENOcR 1.0. DATA: 

{ ~ STATE OF WASHINGTON 



... '''''IVI",TION 

hereby authorize the use 'or disclosure of my health information 

The following individual or organization is authorized to make the disclosure: 

ADD~:~: ~ ~ Jj;:W Jr~ GV'\, k 

~. ~·,S";D>"\.. V....( 

Purposefordisclosure:. \fe r< f>l c .. ,~.=f.·~ V\ ok dA......t1.;:( 

I understand that the information in my health record may include information relating to sexually tI:Bnsmitted 

infections. Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also 

include information about behavioral or mental health services and treatmef1t for alcohol and drug abuse. 

'This information may be disclosed to and used b 

, . NAME: L 

ADDRESS:~ _____________________________________ 

~~~--~~~~--~~~~~~~~~. 

"understand that I have a right to revoke this authorization at any time, I understand that if I revoke this .' 


Department. I understand that the revocation will not apply to information that has already been released in 

response to this aut'7.ati/ Unless otherwise revoked, this authorization will expire on the following date, event, 

or condition:

OF~F.NOER 1.0. OATA! 


DEPARTMENT OF CORRE'CTIONS 




By state statute the Washington State Department of Corrections is charged. with the responsibility to supervise some 

offenders after they have b~en convicted of a felony. The above named patient Is currently under supervision by the 


behavior. Often micit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will impose a condition of supervision that the offender not use, or.possess illicit drugs, 

including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has 

. been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance f~r your 

assistance. If you have questions please feel free to personally contact the Medical Direct~r of the Departmen ··t (360) 

725-8700. 


2. Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 


a. .If the answer to question 2 is "Yes", does he/she have anorexia 

b. If the answer to question 2a is "Yes", does he/she have weight loss 

3.. Are you recommending medical. marijuana for this patient due to nausea and vomiting 


4. 

8. Ifthe ans-,yerto question 3 is 'Yes", has the patient fuiied to respond to conventional 


·OYes 

g¥es 

DYes 

ON/,' 

~. 

DNo 

fJ-No 

~. 

Q-¥es---LJ No 

b. If the answer to question 3a is "Yes', please desc~ibe what those treatments were (medication, dose, 

duration): rJ >r . 1\ -\.. :\,.-\ .. 

\). 1


License#: 

Prescriber: please return th~s form and the patient's Release of Information to: 

lViedical Director 

Health Services DiVision 


PO 80x41123 

Olympia, WA 98504~21 :1.3 . 

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. I have reviewed this verification form and find that use of medical marijuana by this patient 

(check one) lOis 0 is not· . 

consistent with DOC Policy. 

PhYSician's Name (Print) 


Physicien's Signature 



2. File this form and the accompanying Release of Information in Liberty as a CommunityCprrections Health Record. 

Date 

l 

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State law (RCW 10.02: RCW 70.2.4.105: RCW 71.05.390) and/or federal regulations (42. CFR Part 2;AS CFR Part 164) prohibit 

di$t:losure of this Information without the specific written consent of the person to whom it pertains, or as otherwise 



PDU-6655-3 000052

Page 1 of1 

Distefano, Monica J. (DOC) . 

From: Melissa leggee [melissa@cbrmedical.com] 

Sent: Tuesday, February 17, 2009 12:57 PM 

To: 


Subject: 

- DOC Appeal 

Attachments: 200902161606321 

pdf 

Sincerely, 




Spokane 509-242-8624 Fax 509-340-2710 . 

. Seattle 206-774-6493 Fax 206-418-6659 

Tri-Cities 509-416-2267 Fax 509-340-2710 

Vancouver 360-635-6464 Fax 206-418-6659 


Checked by AVG. 

Version: 7.5.5521 Virus Database: 270.10.25/1957 - Release Date: 2/17/2009 7:07 AM 

.5/13/2009 

PDU-6655-3 000053



To: 

o '!Please Comment 0 PI",ase Reply I;J Please ~ecycle 

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Tri-Clties Phone 509-4,16-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTICE: Tllis communication is intended for the sale use of tile individual and 

entity to whom it is addressed, and may contain informatieJll that is privileged, or confidential and 

exempt from disclosure under applicable law. You are hereby liotified that any dissemination, 

distribution, or duplication of tllis communication by someone other than the intended addressee or iis 

deSignated. agent is strictly prollibited. 

All Information is Protected Under U.S, Federal Law 

I. 

PDU-6655-3 000054



AUTHORIZATION fOR DISCLOSURE 

OF HEALTH 

OFFENDER 1.0. DATJ< 

. . hereby ·authorize the use or disclosure of my health information 

as described below. !he following or organization is authorized to make the disclosure: 

NAME: _~C.=I B~R-,-:-"A,--·..!..le."""",Ci...E!.(.L>'-C£!.,!.L=::.(!.-' ---j''':;::S::!:V'.L'' ·_,-C~__ 

ADDRES& __ ~.:5~LIL/~6~--_, __ ~~~.~J21~~/~-3d-~S~,~·d~f~~L. __ ._tr~v~~~~ __ 

. $27,) KA tU ,UYg j' q, 2,f) :2 

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Purpose for disclosure: ______________________________ _ 

I understand that the information in my health record may include information relating to sexually transmitted 


incllJde information about behavioral or mental healtli s!7rvices and treatment for alcohol and drug abuse. 

This information may be disclosed to and used by the following individual or organization: 

NAME: ·iL2I:L 0 ~ :..£j Co, :dJ.J. .a :s::1-cd:..e, . 

ADDRESS:' Q .. ()t;'l"t'lri{fV;+ 'd.Zhcc;ct"oo ~ 

1 understand that I have a right to revoke this authorization at any time. I understand that if I revoke this 

authorization 1 must do so in writing and present my written revocation to the Health Information Management 

Department I understand that the revocation wifl not apply to information that has already been released in 

. response to this authorization. Unless otherwise reVoked, this authorization will expire on the following date, event, 

or condition: :c-7- Q =z (if left blank, authorization will expire six (6) months from Signing). 

I understand that authorizing the disclosure of this health infoimation is voluntary. I can refuse to sign this 

authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the 

information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure 

of information carries with Itthe potential for an unauthorized redisclosure and may not be protected by federal or 

state confidentiality rules. If I have questions about disclosure of my health information,l may contact the 

RHIT/designee of the . 

Signature 

__ form Is 

Social Securtty Number 

'~£4r~5f;£ff- 

2-7-ot 

Date 

(:IiiiiL- 

DOC Number . 

-.2-'2-07 

Signature of Witness . ate 

Slale iaw (RCW 70.02; RCW 70,24.105; RCW 71.05.390) and/or f,deraT reFIII/alions (42 CFRParr 2: 45 CFR 1'01'1 1(4) prohibit a.feIosur, 

a/thiS in/ormarioll withoul the specific ""iltell oonsenl o/lhe person to whom itperloins. or as othenvi.e permilled by law. 

DOC 13-035'(05l1912OOS) POL ' 000380.200 DOC600.02O OOC640.020 DOC670.02O LEGAL 

PDU-6655-3 000055

. ! 





By state statute the Washington state Department of Corrections is charged with the responsibility to supelVise some 

offenders after they have been convicted of a felony. The above named patient is currently under supelVision by the 

Department SupelVision is designed to help the offender avoid those environments or situations that lead to their criminal 

behavior. Often illicit drllg use is a contributing factor in an individual's criminality. Accordingly irs usual that the court or 

th.e Department of Corrections will impose a condition of supelVision that the offender not use, or possess illicit drugs, 


. been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your 


725-8700. . / 

1. Is this patient under Your care E:f Yes 0 No. 

2. 

3 .. 

4. 

5. 

6. 

Are you recommending medical marijuana for his patient due to a diagnosiS of Acquired 


a. If the answerto question 2 is "Yes", does he/she have anorexia 


Are you recommending medical marijuana for thIS patient due to nausea and vomiting 


a. If the answer to question 3 is ;'Yes·, has the patlent~ailed to respond to conventional 


b. 

c. 

DYes ~. 

DYes 

DYes 

If the .an~wer to question 3s· is "Yes", Pleaser~~cr~at those treatments were (medication, dose, 

duration).. 

... . rJ F· '. 

w"" ;,u,,, plaooed ",,",,~Ie of Ch~molh"f! V .. . 

& 

UNo 

oy" ~/ 

DYes .))1fo . 

. If you answered "No" tQ items 2 & 3 above, what is the reason you are recommendmg medICinal use of 

marijuana ... ~~ (C..~ vJ (; 1" ~ ~ 1 A- 

a. Please provide evidence publishedin a peer-revIewed scientific publi tion to support the medicinal use of 

marijuana for this purpose ~ kt· 

WhIle on community supelVision ("parole") the Department of Cor~ections 6~ly aut~oriz~s. t~e 

use of the oral synthetiC formulation of marijuana. If the Department authonzes thiS pattent s 

use of medIcal marijuana, will you be prescribing only the oral synthetic formulation 

The patient's accompanying Release of Information auth'orizes you to pr9vide the . 

Department with current and future information rela,ted to this issue. Do you agree to notify 

the Department's Medical Director of any changes In your answers·above 

0 Yes 

DYes 

/' 

DNo. 

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DOC 14·053 (Rev. 7/31/08) 

DOC 380.200 . 

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PDU-6655-3 000056

dhA-NC,y..:JH. 50,' ~ 

Prescribers Name (Print) • 

License #: J11:P (!) 60 / "3 / I License type: .41 D 

--~~~-------------------- 


3// . E, f{; S 51 DI"l AtltJI Phone Number 

. 4f'z;/:...ctl'l-€ tJq 992/)2-· 

Prescflber: please return'fhls form and the p~tjent's Release of Information to: 



Washington State' Department of Corrections 

PO Box 41123 

Olympia, WA 98504-2113 

»1- 57D-.J-f!8--J> 

. §"O'-).t..f 2- '%"(02.(/ 

To be filled out by DOC PhY$ician: 


(check one) r 0 is 0 is not" 

consistent with DOC Policy. . 



. Date 

Instructions to DO~ Physic,an: 


1. Email your finding above to the Assistant Secretary for Community .Corrections 

2. File this form and the accompanying Release of Information in Liberty as a CommunitY. Corrections Health Record .. 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andfor federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this information without the specIfic written consent of the person to whom it pertains, or as otherwIse 

pennitted by law. 

DOC '14-053 (Rev. 7131108) 

• DOC '380.200 

PDU-6655-3 000057


.DEPARTMENT OF CORRECTIONS 

P.O. Box 41100' Olympia, Washington 98504-1100 


Port Orchard, W A 98366 . 

. DearMr_ 

Your Medicinal Use of Marijuana request was rec~ived on December 23, 2008. Upon review by the 



which is on or before February 16,.2009. Please send. your request to the address below: 



Departn;l.ent ofCQrrections . 

P.O. Box 41126 

Olympia, WA 98504-1126 

I 

I 

Your request must provide additional information that was not included with. your original request. 

Appeals that do not contain new information will be denied. You will receive a response to your, 

appeal request within 30 days ofreceipt. 

KD:md 

cc: Jim Kathan, Community Corrections Supervisor 

Michael Anderson, Community Corrections officer 

.. Field File 

Physician'S Office: 


CBRMedical 



"Working Tog~ther for SAFE Communities" 

PDU-6655-3 000058

Documentation o.f Medical Authorization to Possess Marijuana 

for Medical Purposes' in Washington State 

PATIENTNAME:_' __ DATE OF BIRTH: ~ 

I 

I 

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I,' Dr. Mohammad H. Said , Flm·a physician licensed in the State of Washington 


RCW 69.51A010. 


of marijuana. I have assessed the above named patient's medical history and medcal condition. 

It is my medical opinion that the potential benefits 6f the medical use of marijuana may outweigh 

the health risks for this patient. 

PhysiCian Name: _......;D::::.:.:.r . .:.:lv~·lo::.h::::a.:.:.m::;""~1,a:.::c:..:: H..:.'.:...;S:::.;a~i.:::.d~_ WA License Number: ___\~_D_O_0_b_18_' 3_1_1_ 

Phy,idan Signat""" fL· \. !-f· J ~- Date' __ 

This recommendation expires on: 

07/27/,;;:2""0,::.09=--__ _ 

..;..07;.;.f2;..;.;7~f2;;;..O..;;.0.o..B __ _ 

Risks and benefits of medical marlj'uana 

Under Washington law. t"'e use. of rT'sdical marijuana is now permissible for some patients 

with terminal.or debilitating illnesses. The law regLilating this (RCW 69.51A) allows pr.ysicians 

to advise pati~nts about the risks and benefits of the medical use of marijuana. 

The medical and Scientific evidence supporting the use of medical marijuana remail.ls 

controversial in the medical community. Not all health care providers believe that medical 


According to the Washington State law the benefits of medical marijuana may incli,Jde 

. treating nausea and vomiting from chemotherapy, AIDS wasting syndrome. severe muscle 

spasms from multiple scferosis or other spasticity disorders, glaucoma, and some types of 

intractable pain-. 

Some of the risks of medical marijuana may include possible long-term effects of the bralr..i~' 

the are.as of memory, coordination and cognition; impairment of the ability io drive or operate 

heavy machinery; respiratory damage; possible lung cancer: and physical or psychological 

dependence. 


As.this patient's "60 day supply", as stipulated by RCW 69.51A(2)(b), I rec

T.)' 

~x.. 

MARIJUANA MEDICINE'· 

'EVALUATION CENTI;RS 

1512 Artesia.Bl"d. #120 

Redondo Beach. CA 9027& 

24 Hour Vertfit:ation 800.268.4420 

Or Verify Online at: W\\"\\ .mari i uan'amedicine.com Click on "Dispensaries" Tab 

PHYSICIAN'S STATEMENT 

Health & Safety Code Section 11362.5 

This certifies that __ was evaluated in my office for a medical condition, 

which in my professional opinion, may benefit from the use of medical marijuana. I have 

discussed the potential risks and benefits of medical marijuana with the patient. I approve his/her 

use of marijuana as medicine. If my patient chooses to use marijuana as medicine, 1 will continue 

to monitor hislher medical condition and to provide advice on hislher progress at least annually. 

In addition, I have inforined my patient to infonn me of changes to said medical condition. '1 

have informed my patient not to drive. operate heavy machinery or engage in any activity that 

requires alertness while using medical marijuana. . 

Pursuant to California HS 11362.5, Compassionate Use Act of 1996, also known as Prop 215, 

with this recommendation my patient is pennitted possession of medical marijuana in quantities 

pursuant to California HS 11362.77 and SB 420~ 

Signod, L fr-:>L 

Kien Tran, M.D., 

' 

Date of statement: ___--l!.05~-:.±1!!:6-~2~OO!!.!8L_____ 

Time Period Covered: 

3 Months 16 ~,ion~nths I Other _. ____ _ 

Expires: 05-16-2009 

Patient ID Number: ......a- :,~~,;' , , 

Note: This is nOl a formal prescription. /nit is a statemem ojmy professional opinion. This opinion I~ . 

consultant with expertise in Internal Medicine, and e).·perience in pain managemenr and n~l the capacltJl o( a 

'mary care pl'o~·ider. This recommendallon is in IIV ·.I'ay 10 be imerpreled as a prescrIpllon as defl·'le

. , 

I 

I Fax 

. CBR Medical, Inc 



, 

·1 

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D Urgent D For Review D Please Comment D Pleasl~ Reply D Please Recycle 

-Comments: 

. CBR Medical, Inc, - 3115 E. Mission Ave.. Spokane, Wa 99202 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509·340·2710 

• Tn-CIties Phone 509-416-2267 rax 509·340-2710 Vancouver Phone 3IS0-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTICE:. This communication is intended for the sole use of the individual and. 

entity to whom It is addressed, and may contain information that is privileged. or confidential and 

exempt from disclosure under applicable law_ You are hereby notified that any dissemination, 

distribution, or duplication of this communication by someone other ihan the intended addressee 01" its 

deSignated agent is strictly prohibited. . . 

: AU lilfonnation is .Protected .Under U.S. Federal \...aw 

PDU-6655-3000061

.,.,... ..,..,.~ 

f~J STATE OF WASHINGTON 

...., DEPARTMENT OF CORRECTIONS 



j. 

I , 

r· 



offenders after they have been convicted 'of a felony. The above named patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid thOse environments or situations that lead to their criminal 

behavior. Often illicit drug Use is a contributihg factor in an individual's criminality. Accordingly it's usual that the court or 



been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your' 

assistance. If you have ql!estions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. 

1. is this patient under your care 

2. Are you recommending medical marijuana for his patient due to a' diagnosis of Acquired 

Immunodeficiency Syndrome (AIDS) . 

a. If the answer to question 2 is'"Yes'', does he/she have anorexia 

b. Ifthe answer to question 2a is "Yes", does he/she have weight loss 

3. Are you recommending medical marijuana for this patient due to nausea and vomiting 

associated with cancer chemothe~py 

a. If the answer to question 3 is "Yes·, has the patient failed to respond to conventional 


Gives 

DYes 

DYes 

DYes 

DYes 

DYes 

b. If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose, 

duration): 

rJ(V' 

c. 

What is the planned schedule of chemothera~YII\---- . . . 

ONe 

B< 

~ 

~ 

~. 

~. 

4. 

If you. answered "No" to items 2 & 3 a!;love, what is the reason you are recommending medicinal use of 

marijuana ~,'Vr9%. ~_ ~tU h 9,~! If . 

a. Please provide evidence published in a peer-reviewed scientific pub icatien to support the medicinal use of 

marijuana for this purpose' F-t.. 'e... . M,....."-

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- 


--~~------------------ 

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 



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: _________________________ --------------------- 


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




DATE OF BIRTH: --"__;..:...:;..'-- 

I., Dr. Mohammad H. Said ,am a physician llcensed in the State of Washington 


ROW 69.51A.010. . 


. of marijuana. I have assessed the above named patient's medical history and medical condition. 

It Is my medical opinion that the potential benefits of the medical use of marijuana may outweigh 


. Physician Name: __ =.D.:..:;r .....;.M;.;;o;;;.:;h.;.;;a;.:..m;.;.:m~ad;;...;..;H"- 

. .;;:;S.:;;.ai"'d:...-__ WA License Number: ___ M_D_O_O_0_1_8_31_1_ 

Physician Signature: 


Risks and benefits of medical marijuana 

Under Washington law, the use of medical marijuana is now perll}issible for some patients 


to advise patients about the risks and benefits of the medical use of marijuana. 

The medical and scientific evidence supporting the use· of medical marijuana remains 

controversial in the medical community. Not all health care providers believe that medica! 

marijuana is safe or effeCtive and some providers feel that it is a dangerous drug. 



spasms from multiple sclerosis or other spasticity disorders, glaucoma, and some types ·of 


Some of the risks of medical marijuana may include possible long-term effects of the brain in 


heavy machinery; respiratory damage; possible !ung cancer; and physical or psychological 

dependence. . 


As this patient's "60 day supply", as stipulated by RCW 69.S1A(2)(b), I recommend 24 ounces 

of dried, cured marijuana and as many plants as the patient feels necessary to maintain this "60 . 

day supply" .. 

CBR Medical; Inc. 

Administrative· Office 



Spokane: 509-242-8624 

Seattle: 206-774-6493 

Revised 7/07 

PDU-6655-3 000065

-----------------------_ 

Brown, Damon K. (DOC) 

From: 

Distefano, Monica J. (OOC) 

Sent: 

To: 

Subject: 

FYI- 

Mr_request has been denied. 


Executive Secretary to 


Community Corrections Division '. 

7345 ·Linderson Way SW 


(360) 725-8796 


I , 

I 

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; .. , 

i 

From: 

Sent: 

TOI 

Subject: 

Not consistent with our. policy 

... --,,_.- ... 

Tuesday, December 09, 20088:31 AM 

Bro~lIs, JackW. (DOC) 

FW: ___ MM Authorization Request 

Hammond, G. steven (DOC) 

Monday, December 08, 2.008 4:37 PM 

1-1- ... -.: .... 

MM Authortzation Request 

G. Steven Hammond PhD, MD, MHA 

Director of MedIcal Services 



POB4:1123 . 

Tumwater, WA 98504-1123 

360-725-8700 

i 

PDU-6655-3 000066

Nov. 16. 2008 4:36PM CBR Medical Inc. No. 2425 p, 

3115 E Mission Ave 


To: 

"Comments: 

o r':'r Review 

-----,.. 

Pa,ges: 'I .. ---:.... -....: ... _._~ . 

1-_. CC: :OO(,.··4.:¥___- 

n l'lnase Commfltlt . IJ 1'1.,3se Reply . D Please Reoeyc:fo. 

- -_. --- '--'-- ---. ._- 

DP14 --- 

OTC ......... - 

~~~~ teID 

DP'l9_ 

DP1B·_ 

CRM- 

RECEIVED 

Dtc D 12008 

DEPT 0'- , 

SHELidN c:::~;RECTtON'S 

. '. I '-I..D OFPIGE . 

OBI-{ Medical, Inc. - 31'10 E. Mlsslol1AIJ6, Spokane, Wa 9920 

SO!.lWe Phr)ne 206-7746493 Fax 206·1\18·-6659 Spokane Phone 509 .. 7.42·862.4 1-ax (309-340·2710 

Tri-Ciiics Phone 509-416--2.267 Fax 509-340··;r/10 Vancouver r~honlD 360-t:i3f3.6464 Fax 206·418·6659 

CONFIDENTIALITY NOTICE: ThIs commullication is intflndecl1'or the sale use of the individual and 

entity to whom it Is Addressed, af)d may contain inf'Ormanon tllat is privileged, or c:onfJdentlal and 

exempt from disclosure Linder appUc:able law. You are hereby n

Nov. 26. 2008 4:37PM CBR Medical Inc. No. 2425 P. 2 


DEPARTMENT OF CORMOTlONS 


OFFeNOER 1.0. DATA: 

DEC J'llOOH 

DEPT Or OORReCTIONS 

SHELTON FIELD OFFice 

Dear Prescriber; 

By state statute the W~shin9ton State Department of Corrections is charged with the responsibility to supervise some 

offenders after they haVe been oonvlcted 01 a felony, The above named patient is currently under supervision by the 


behavior. Often illicit dl1lg use is a contributing factor in an individual's criminallty. Accordingly it's usual that the court or " 


including marijuana. This offender has claimed that they halle a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their- claim. Thank you in advance for your 

assistance. If you have Questions please feel free to personany contact the Medic~1 Director of the Department'3l: (360) 

725-8700. " /' ' 

, ' 

; 

1. Is this patien~.under your care ~ 0 No 

2. Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 0 Yes' g.~ 

Immunodeficiency Syndrome (AIDS) , . 

3, 

4. 

8, If the answer to question 2 is "Yes", does he/she have anoreXia 

b. If the answer to question 2a is "Yes", does he/she h

No v. 26. 2008 4: 48PM CBR Medical Inc. : .. No. 2425 P. 3/5 

~- 

••_0'·' .. ~~I-' " .....- 

_ of' .... ...fI' ~ 

9 

__,/~"",:,~..,;,:--..:... t. ..\)~ ~\ ..;_.~".. ,...... ~_ ."..,"' ~~ ___...._...... /,.r,,}."//,.I"):- 

Preeo~l"rint) . Proscriber's Si!1natu --___..L q"jj;(' -:-.---=--- 

License#: ... ~_ .... :-~ ~''''''J' .~"'\;i.~ .~••.. _.__. rJ!6ense ty~~:, ... j')_ ../.)-:::."-__--=__ 

Prescriber: please return this form ~nd the patient's Release 'of Information to: 

Medical DireCtor 


Washington state Del'iartmerit of Corrections 

PO Box 41123 

Olympia; WA '981504-2113 

----.:. 

-~---..- ....._----.- 

To be filled oLit ~Y DOC Physician: . 

I 

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.......__.. "./' \",... /.... 

. '\ -'- "I"~ I VII',' "';I~. (" l.".~ .... ) -Iff'. ...,..:: )-.. .., • ;;- .. (0 •• J,) ",. "_~~:~_". I Phone 1'Iumber '

No'v, 26, 2008 4:48PM CB R Me d i ca 1 Inc, No, 2425 p, 4/5 

Documentation of Medical Authorization to Possess M~rUlJana 

for Medical Purposes in Washington state 

PATIENTNAME: ______ DATEOFBIRTH:~ 

j 

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I, Antoine Joh!l~!l. __,___.., am a physician licensed in the State of Washington' 

and I am treating the above patient for a tetminaJ illn~$..ar·ajdebilitating condition as defined b¥ 

RCW 69.51A.010. . ./. J '. 

I have advised the above named patient about.tlie potentiaVrisks'and beMfits of the medical use 

of marijuana. I have assessed the above nartied patlent'sAnedical history and medical condition, 

It is my medical opinion that the potentiaU:5enefits of the rhedical use of marijl.lana may outweigh' 

the health risks f9r tfiis patient. 

Physician Name: _· __ .gL~n~oine..:.johnson 

i 

:.:.. :-" 

/ WA License Number: __ Mtl00039048 

." 

,.,.... " . ~#,." • 

Physician Signature: .: ..L.~" Daie: 08/24/2008 

. . --"".;------ ~ ;:.=..:;.;;.;;.;;.;;-----;... 

This re·com.mendation eXPir~s on: _...QB/27;1!:~/-·-'-- 

I. 

Risks and benefits of medir-al marfiuanV :-" - . 

. Under Washington law, the US~Of edreal marijuana is now permissible for some patients 

with terminal or debilitating ilInesse " T1fe law regulating this (Rew 69.51A) allows physicians 

to advise patients C1Pout the risks nd qenefits of the medical use of marijuana, 

. The medical and scienlific e.lden~~ supporting the use of medical marijuana remains. 

controversial in the medical cytmnuOlty, Not 0111 health care prov(dets believe tllat medical 

marijuana is safe or effet:tivrand s.ome providers feel that it is a c1angerous drug. 

According to the WElshil)!lton State law the benefits of medical marij~lana may include 


spasms from multiple scl¢rosis or other spasticity disorders, glaucoma, and some types of 

intractable pain. f" • . 

Some ·of the risks Of~llhedical marijuana may include possible long.:(erm effects of the brain .in 

the areas of memory, c orqiha\ion and cognition; impairment of the.. ability to drive or operm.te . 

heavy. machinery; respl ataTY damage; possible lung cancer; and physical or pE;ychologlcal 

dependence. '-:'. . 

Recommendation . 

As this patient's "60 day s~lpply", as stipulated by RCW 69,S'IA(2)(b), I recommend 24 ounces 

of dried, cured marijuana and as meny plants as the patient feels necessary to maintain this "60 

day supply·. 



3115 E, Mission Ave 

Spokane, WA99202 

Spokane: 509-242-8624 

Seattle:. 206-774-6493 

RevIsed 7/07 

PDU-6655-3 000070·



I 

I 

I 

I 

I 

I 

PATIENT NAME: ___ _ 

DATE OF BIRTH:~ 

I, Antoine ,Johnson , am a physician licensed in the State of Washington 

and I am treating the above patient for a terminaZilines debilitating condition as defined by 

RCW 69.51A.OiO. 

' 

I have advised the above named patient about! e potentia risks and benefits of the, medical use 

of marijuana. I have assessed the above n !'fled patient's edical history and medical condition. 

It is my medical opinion that the potentia enefits of the edical use of marijuana may outweigh 


' 

Physician Name: --::.:.:..:..:!.!==r==~---I- 

MD00039048 

Physician Signature: __-+____/_-+_-:::=_ 

0812412008 

This recommendation eXPlr{s on:·"""';:'=::"'::':=joz:;.. __ _ 

Risks and benefits of medicalmarljuan . . 

Under Washington law, the use of ~. al marijuana is now permissible for some pafieh~ 

with terminal or debilitating iIlnesse . T law regulating this (RCW 89.51A) allows physicians 

to advise patients about the risks n~ nefits of the medical use of marijuana. 

The medical and scientific e denc supporting the use of medical marijuana remains 

controversial in the medical c m~ ty~ Not all health care providers believe that medical 

marijuana is safe or effectiv and s me providers feel that it is a dangerous drug. 

According. to the Washi ton ate law the benefits of medical marijuana may include 

treating nausea and vomit" 9 fro chemotherapy, AIDS wasting syndrome, severe muscle 

spasms from multiple sci rosis r other spasticity disorders, glaucoma, and some types of 

intractable pain. . . 

Some of the risks of edi I marijuana may include possible long-term effects bf the brain in 

the areas of memory, or' 'ation and cognition;. impairment of the. ability to drive or operate 

heavy machinery; raspi ry damage; possible lung cancer; and physical or psyChological 

dependence. . 

.J . 

. Recommendation 

As this patienfs "60 day supply", as stipulated by RCW 69.51A(2)(b), I recommend 240lAnces 

.of dried, cured marijuana and as many plants 1'1S the patient feelS necessary to maintain this "60 

day supply". . 





Spokane: 509-242-8624 

Seattle: 206-774-6493 

Revised 7/07 

~IQS.\vI\,) 

SE~ 

;.,JlUQ8. 

...'.;'" 

··~ECt\t3~' 

OE.~T 0XkP~~bD e~f;:\~i 

SH€.i:.T ~::,,~ 

. i 

PDU-6655-.3 000071

.~. :.' 

'. 

ATTEN1':tON LAW ENFORCEMENT, 

Patient Form 

I 

/' 

\' 

! 

I am CI teg!ll medical marijuana patient, as defined by the Washington Medical Marijuana Act, RCW 

69.51A. A copy of that document is attached to this letter. I have also attached a. co~y of my 

Physicians Recommendation as required by RCW 69.51A.C~R Medical, Inc. Qnd its affiliated 

physiclaM contact Vlllmbers are: Saattle:, 206-774·64513 or Spokane 509-242-8624. I have also 

attached ct c.0W of my Washington State Drivel' LicI!MeIIO, as well as a copy of this patienfs 

Washington stqte Driver License/ID. 

' 

I am in possession 'of less than my hecessary "60 dCly eupply"as de.fined by RCW 69.51A. I will not 

answer any questions as related to my status as Q qualified patient, my medical condition, my dosage 

requirements or the number of plants that I need to meet my "60 day supplyU or any other 

questions regarding my medical condition or medication. This Information is confidential and'is 

strictly proteeted under the Federal HIPAA law that protects the confidentially of my medical 

information. Requesting this Information, without Q subpoena. violates my right against selfil1Ol'lmination. 

' 

Furtherlnore, I will not speak with ,you unless lain C1ceompanied by my attorney. Any ftlrther 

attempt to speak to lne without the pr.esence of my attorne.y will be considered coercion. I do not, 

and wlUnot. agree to Cl search of my home. person. property, or vehicle. under allY circumstances, 

without a search'Warrant. 

ihi~ Letter I the copy of my Physician's Letter of Authorization, a copy of Illy Washington State 

Mver Licel'\SeIID, and a copy of RCW 69.51A eire being provided for YOLlr records and incident 

report I encourage revie.w of this documentation before taking action . 

.._...-_..._.. 

PDU-6655-3 000072

OFFENDER I.D. DATA: 




Dear Prescriber, . 

I;!y state statute the Washington State Department of Corrections is' chiarged with the respon~ibility to supervise some 



behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly ifs usual that the court or 



been recommended. The below verification is 10 determine the legitimacy of their claim. Thank you in advance for your' 

assistance. If you have questions please feel free to 'personally contact the Medical Director of the Departmer:Jt at (360}' 

725-8700. 

. 1. Is .this patient under your care 

DYes 

'. 2. 

Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 

immunodeficiency Syndrome (AIDS) 

a. . If the answer to question 2 is "Yes", does helshe have .anorexla 

b. If the answer to question 2a is "Yes·, does helshe have weight loss 

DYes' 

DYes 

DYes 

DNo 

DNa 

DNa 

3. Are you recommending medica.1 marijuana for this patient due to nausea and vomiting 


DYes 

DNo 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional . 0 Yes 0 No 

. antiemetic treatments . 

b. If the answer to question 3a is ~Yes", please describe what those treatments were (medication, dose, 

duration): . . . . 

c. VVhat is the planned schedule .of chemotherapy 

4. If you answered "No" to items 2 & 3 above, what is the reason you are recomm ending 'medicinal use of 

marijuana . . . '. 

a. Please provide evidence published in a peer-reviewed scientific pUblication to support the medicinal use of 

marijuana for this purpose 

. . . 

" 

5. While on community supervision (·parole.~) the Department of Corrections only authorizes the 

use of the oral s'9litlietldf6tmulatlon of mariJuana. If the Department authorizes this patient's . 0 Y~s 

use of medical marijuana, will· you be prescribing only the oral synthetic formulation 

ONo 

1· 

6. The patienfs accompanying Release of Information authorizes you to provide the 

Department with current and future information rEllated to this issue. Do you agree to notify 

the Department's Medical Director of any clianges in your answers above 

DYes 

DNa 


ooe3S0.2no 

PDU-6655-3 000073

\"'Ior"'.~ 


I f STATE OF WASHINGTON 

DEPARTMENT OF CORRECTJONS 




IIIU'VlllU

THCF Medit:al Clinics 

1813 130 th AV,e. NE· #210 

Belle\lue, VI/A 98005 

Phone: 425-869-6186 or 800-723-0188 

Fax: 425-869-6378 

www.thc-foundation.org www.hemp.org., . 

Documentation qf Medical Authorization to Possess Marijuana.,for Medical 

, .. '. Purposes in Wa~hington State, ( ,,' . 

. The te~t of this ,~O(J1i,Wf.lS recommended by the Washington State Medical ASSQgi:~tlon, 

. . '. . : .;t.- .... : 

Patien~· Name: 

. Date of Birth- 

I 

I 

I I' 

I 

I ;. 

j 

! 

I, Thomas a physician licensed in the state oniVashington. I am treating the 

. , above named' , a terminal illness or a'Ci"l:!pilitating condition as define~ in the RCW 

69,51A.OIO. h.ave.,~L1'iiised the above named t:>atient about the potential risks .and benefits of 

the the medical use',oJ marijuana. I have assessed the above named patient's medical history 

and medical condil;i9..~. It is my medical opinion th,at the potential l:ienefits of the medical use of 

marijuana would lik¢l¥ outweigh the health .risks fqr this patient. 

' 

... ~ .. 

Tod~y'~ bate: 4)~be C Ol..\ db()...1L- Exp~ratlon Date: t;lec-p,'Q'"\);)( ,r" 

Risks and benefIts .pf medical madjuana:-t. 

.. , .... . ~ 

C)Y r.9cL:J1 

Under Washington state law, the use of medical marijuana is now permissiQle for some patients' 

with terminal or debilitating iI!nesses. The laws re~ulation this (ReW 69.51A.) allows physician's 

to a.dvise patiel:l~~ ab.out the risks and benefits of t9.e medical use of marijuana.; ; 

The medic~! a~d':s~.i~~tjfiC evidence supporting th~. use of medical marij~ana fe;~ai.ns . 

controversial in the m~9.ical community, Not all, h~~lth care providers believe't1.u.at medical 

marijuana is safe or eflJective and some providers f!,!el that it is a dangerous drug,. 

. • ~ t· .. 

. According to the washiJ.lgton state law the benefits of medica! marijuana may glduqe treating 

nausea and vomitilig'l;t~m chemotherapy; AIDS wasting syndrome; severe mu~de spasms from 

multiple sclerosis OT otrler spastIcity disorders; glaucoma; 'and some types of in~ractable pain. 

!. • • • ..... 'i ~~l .:~{. .• 

Some o(th~ risk~::~ff.'B.~di¢a'l 

marijuana may inclu~~-possible long-term effe~t~ of t,he brain in the 

: areas of memory, ·coP'ftlination and cognition; impllirment of the ability to drive.,:or operate heavy 

machinery; respirC:!t9rY, damage:; possible lung cancer; physical orpsychofogical dependence·, 

, " 

" .:' 

' ... , 

R.ECEIVED 

, fE~ 042009 

OFFENDER COpy 

o.SPT Of COR~EOTrONS 

. SHELTON rlELD OfFICE 

PDU-6655-3000075

Wheeler, Judine L. (DOC) 

From: 

Sent: 

To: 

Cc: 

Subject: 

Attachments: 

Daniels, Karen R. (DOC) 

Thursday, March 19; 2009 11 :01 AM 

DOC DL ALL CCD STAFF , 

Vail, Eldon W. (DOC); Strange, Cheryl E. (DOC); Blonien, John 'Scott'; Hammond, G. Steven 

(DOC) 

CCD Medical Marijuana Process Changes Memo 

Medical Marijuana Process Change 031309.pdf; 14-053 Medicinal Marijuana Form 

031609.doc 

Good moming! Please see the attached mellio which identifies changes in the current medicinal marijuana, 

---Pi'(Jc-es'S:-rveaI'S,nrtt~[(:;lred-Fm'firl*05"'3-wl'Ii:(':lrWlf:rlll'dro:-ed-urr;3tt6i09-ro-:reilm:Ltl:re~h1fIIg"e-hrproc-ess. ---- 

In addition, I've broken down the process to give you a little guidance on timeline expectations. 

Please feel free to contact me army assistant, Monica Distefano, if you have any questions. 

Thank you! 

rm 

Medical Marljuarla 14-053 Medlclrlal 

Process Chan... Marijuana For ... 

i 

I 

'Karen 'DanIels 

Assistant Secretary 

Community Corrections Dlvlslorl 


7345 Llnderson Way SoN 

Tumwater, WA 98504 

Office: 360-725-8787 

Cell: 360-791-7768 

Fax: 360-586-0252 

email: krdanlels@doc1.wa.gov " 

r 

1 

PDU-6655-3 000076

j 

=1 

I 

I 

! 

. OMNI: Chrollos Quick Search 

Page 1 ofl 

I 

Field 

Gender: Male 

00B:_1979 

Age: 29 

Body Status; Active FIeld 

RLC: HNV 

Wrap-Around: No 

COInIn. Concern: No 

Location: "Ep.!1rata OffIce 

SED: 

02/28/2010 

County SO Lvi: 

ESR SO LvI: 

CC/CCO: Green, Amanda L 

Details 

Date 8< TIme Created: 03/30/2009 01:05 PM 

Offender Location At Occmence; N/A 

Date & Time Of Occurence; 03/30/2009 

DOC No.: 315911 

Offender Name: ••••••••• 

Author Name: Amanda Green 

Events: Office Off~nder ( OP ) 

Date & TIme Created: 03/24/2009 09:25 AM 

Offender LOCation At Occtlrence: N/ A 

Date & Time Of Occurence: 03/23/2009 

DOC No.: 315911 

Offender Name: .•••••••• 

Author Name: Amanda Green 

events: Home Collateral ( HC ) 

Text 

P reported to the offIce and requested a TP to Spokane for a doctor's 

appointment. P signed a stipulated agreement and will be reporting . 

weeldy for the next 4 weeks. He did let me kl1o~ the appoIntment was 

for medical marijuana. I asked him which type oe would be 

request/ng/usl~g, m'arlnol or marijuana, ~nd he stated marIJuana. I gave 

P form 1

OMNI: Chrollos Quick Search , •• ___ •. ~, 

Page 1 of'l 

Field Offender: 

I 

I' 

Gender: Male 

. RLC: HNV WI'ap-Arollnd: No 

Comm. Concem: No 

Body Status; Active Field 

Location: Ephrata Office. 

SED: 

04/23/2009 

Counly SO Lvl: 

ESRSD Lvi: 

CC/CCD: Green, Amanda L 

Details 

Date 8< Time Created: 01/28/2009 06:11 PM 

Offencier Location At Occurence: N/A 

Date 3< TIme Of Occurel1ce: 01/28/2009 

DOC ~Jo .• : 987523 

OffenderName:.- 

ALithor Name: A~ 

. Events: Office Offender ( OP ) . 

Text 

P reported as directed. Gave P forms for medicinal marijuana, P also 

requested a TP to Bellevue on 01/29/09 for medical purposes. TP 

approved. P Indicated on hIs monthlv.report that he receIved a tlcl


From: 

Sent: 

To: 

Subject: 

Allim, Kimberly K. (DOC) 

Tuesday, May 05, 2009 12:43 PM 


FIN: Help 

Here is the other chrono - CCO Green didn't have anyone else. 

Date & Time Created: 03/05/2009 10: 17 AM 

Offender Location at Occm·ence: NI A 

Date & 03/04/2009 

DOC No.: 

Offender Name: 

Author Name: Rebecca Saclanarm 

Events: Office Offender ( OP ) P reported today. He had paperwork from THCF Medical Clinics, which is the, 

statement regarding medical mal'ijtiana. He said that he can't deal with his pain from losing'his leg. He was 

addicted to opiates and all the doctor's want to do is give him pain medication. He's afraid to take it so he was 

seeking alternatives. I explained to him that this was not a prescription and he cannot smoke marijuana for his 

pain as it would be a probation violation. We discussed a marinol prescription and I advised him to talk to his 

doctOl: about marinol. I also asked him ifhe talked to Kathy at ADDS about this. He· said that he hadn't because 

he wanted to talk to me first. He said that he won't make the order from this "doctor". He said ·that his daughter 

is better and he's been takfug care of.heJ.'. He's still seeing Kathy at ADDS regularly and making progress there. 

'I'm afraid that this marijuana issue will set him back. UA was submitted, he reports no contact with law 

enforcement. He made hisappt for next month. 

Kimberly Allen, MJA 

Community Corrections'Supervisor 


229 1st Ave NW 

P.O. Box 159 

Ephrata, W'A 98823 

, Direct Line - (509) 754-6989 

Fax· (509) 754-3617 

From: 

Sent: 

To: 

Subject: 

Yes, mine was 

Sackmann, Rebecca E. (DOC) 

Tuesday, May 05, 2009 12:40 PM 

Allen, Kimberly K. (DOC) 

RE: Help . 

From: 

Allen, Kimberly K. (DOC) 

Sent: Tuesday, May 05, 2009 11:44 AM : 

To: 

Green, Amanda L. (DOCl; Sackmann, Rebecca E. (DOC) 

Subject: 

FW: Help 

Importance: High 

,1 

PDU-6655-3 000079

-...... 

THCF MEDICAL CLINICS 

1813 130 th Avenue NE Suite 210 . 

~eI1evue, WA 98005 

';ii~J:ibh~;(4~1;7{glf~~F8"6 ·~'lE'liil~~~··8tiqt\6.:al8 

~\. ~. .. ... :.,.. ~:.,\~@;i.M:."ii' 

• "'t. 

D,;~umei.tation of Medicaf .Al!t~:y~,;.zation to Possess Marijuana. 

for Medical Purposes m Wasbingto~ State, 

The te:ct -of this form was reCommended by the Washlngton State Medical Association., 

Patient 

r, Thomas Orvald" am a physician licenSed in the State ofWashingtoll. I. am. 

treating the above-named patient for a terminal ilkI~is or a debilitating condition as defined 

in RCW 69.51 A.01D. !'have advised the above nt'Pned patient about the potential risks and 

b~nefits ofth~ n:edical u~e. ofm~j1;lana .. I ~avei~~~~e~ the above n~ed p.a*nt·s medica! 

hlst~ry and medlca~.~nchtlon. It.IS my me~B~p' '\ .. !;mthatthlfP!lt~~l~~'~~S oithe .' 

medICal use ofmanJt1ana would likely outwelgl1:t • ealth rlslci forthis patient!. 

. 'r" 

Sign~tuTe ofPhysici~; 

~~~ (}fb.c&R..ek ft~ 

ThomasO. Onaid, M.D. WAif MD 00016180 

Tooay's date: l;L ~ l L.l- ZtoB Expiration date: ll- l Y -200 9 

Risks and benefits ofmedica]marljuana: 

Un.der Washington·state law, the use of meaical marijuana is now permissible for some patients 

with. temUnal or debi1itlrtmg illnesses. The law regulating this (RCW 69.51A) allows physicians 

to advise patients about the risks and benefits of 'the medic~ use of marijuana. 

. ' . 

. ~.fit_. ':C-~\ ._H' ... 1,. ••••• "", ...·~1 ~~~ .. 1. " . 

The medical and s

~ 

\ 

/ ........ 

; '\. 

! ~\ &TATE! 01" WASfoIINGTQ!f 

......,. CEPAATMiiNTOF COI'lREC'I'lO,!8 

Mea'Qlna1 Use of Marijuana V~rification 

~~--------~--~ 

To be flll~ out by F'rQ8crl~er! 

rYl.6t.ti'l ~~ 1 Srw.\iJr\ 

i\:" 3.;L 'IfIi.:) g 

_ . .. -- . 

. _L!!.-.~ -----!11iIIiI=J 

DeBr Prescriber, '. . • ". 

'Sy &tate statute Ihe WaShington Slate Oepanrnent ofCorreClions is charged with the responsibility to SUjleNlsa llama 

offenders aftar they have i)eerr,cohvic!ecl of a felony. The) above named patient 15 CfJrrently under stJpervlelon by lhe , . 

DepartmenL Supervision Js designed to help the offenderaVQid \hasa 5nv!ronmants or srtoalfons Ihat lead to their qriminal 

behavior. otten Illicit drug use iii a q

Prescdbar's Name (pnnt) . Prasc~jjetlSl911a\I,Jte Datil 

~ .... ~~'"


, 

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

- ...-------------- _._.-- _ ..-----'-- -_. 

i 

I 

r 

• 

Fax Cover Sheet 

! ' 

TIICP Medical Clinic 

Thomas Orvald, M.D. 

1-813 '130 ih 4venue NE, Suite 210 

Bellevue~ w.: A 98005 

K 

Phone: (425) 869*6186 Pax:: (425) 869 6378. 

, , 

To: boc " From: '. e",,;1N'\.. 

Date: 

,3 - {j-c9,· 

Phone: _--'-__ --'--__ _ . 

Phone: 

Pages! 

.2. +C9J~V 

.- 

'Re: 

----~--~----~~--~--~~----~------- 

;~ 'qV\ 

:T. 1 

Notes: 

PDU-6655-3 000084

From: 

Serthon, Ralph M. (DOC) 

Sent: 

Friday, April 17, 2009 6:44 PM 

To: 


Subject: . FW: 3aO 200 Community Supervision of Offenders 

Marijuana disclosure 

. From: Serthon, Ralph M. (DOC) 

Sent: Thursday, April 02, 2009 7:36 AM 

To: Witten, Dell-Autumn W. COOC) 

Subject: RE: 380 200· Community Supervision of Offenders 

You're number 1! 

. From: Witten, Dell-Autumn W. COOC) 

Sent: Wednesday, April 01, 2009 3:46 PM 

To: Berthon, Ralph M. (~OC) 

Subject: RE: 380 200 Community Supervision of Offenders 

Thanks Ralph! There is already an AS in the works for the violator policy, so I will work with Lin 

on adding the violation language to it. I will need to check around on moving the medicinal 

marijuana language; bufif I get clearance can move that in the same AS: ' 

Also, we are currently working on-improving the process for making changes to policy between 

scheduled reviews. So hopefully your frustrations will be'addressed soon! 

Have a great afternoon, 

Autumn 

From: 

Sent: 

To: 

Subject: 

Berthcin, Ralph M. (DOC) 

Wednesday, AprtlOl, 200912:04 PM 

Witten, Deli-Autumn W. (DOC); Meusborn-Marsh, Stefani L. (DOC) 

FW: 380 200 Community Supervision of Offenders 

Folks, 

I really cannot tell you how many times I have seen this policy or ,who all have sent it to me 

for review in the past year. I am excited (I hope it doesn't show!) to see we are close to 

putting it to bed. I have read this version and made one minor change that 1 can live with or 

without. It has to do with the ten day contact rule. I added a couple of words in regard to 

intakes as it is not captured in the intake policy 310.100. 

In regard to Autumn's remarks below, I can see adding the KIOSK language because it 

directly applies to supervision on a global scale. 

As for the violations language, we need to take it out and do an Admin Bulleting (AS) to the 

violations policy. In this case the violation dat~ can be captured in an AB, the new 380.200 

can go out, when the violation policy gets a re-write we add the AB data and .we are all 

happy. Well almost all of us. And of course the same logic applies to the Community - 

Supervision of high Risk offender's piece; take it out, put it into and AS and be done with it. 

The medical marijuana piece; that too belongs in a violation policy as it related directly to the 

process for establishing credibility to violate someone. In that there is an AS already out on 

marijuana, we could amend that bulletin and re issue it and tie it to the violation policy. 

Two more cents worth: 

PDU-6655-3 000085

I 

I do ncit want to ruffle feathers, and it may be'showing a bit but one area that I feel strongly is 

these are easy fixes to a difficult process of re-writing policies. I will admit that having AB's 

, come out all the time seems to makes us look a little disjointed and lacking in direction, but it 

is what it is. From one persons perspective it is not a good enough reason to have policies 

,constantly changing or in "draft" status for months/years while stuff is pending a change in 

another policy; or to issue a policy knowing we will have to re write it again and then just not 

getting to it for a year or more. If we are planning any policy change then let's shoot for 

making it a singular one time fix to a policy instead of having to re-write one policy every time 

'we re-write another policy. 

' 

Ralph 

F~om: Witten, Dell-Autumn W. (DOC) 

Sent: Wednesday, April 01, 2009 9:21 AM 

To: Berthon, Ralph M. (DOC) 

Subject: FW: 380 200 Community Supervision of Offenders 

« File: 380200.doc » 

Here you go. Let me know if you have qU(3stions. Thank you! 

From: 

Sent: 

To: 

Subject: 

-Meusbom-Marsh, Stefani L. (~OC) 

Monday, March 30, 2009 10:43 AM 

Berthon, Ralph M. (DOC)i Witten, Dell-Autumn W. (~OC) 

PN: 380 200 Community Supervision of Offenders' 

Ralph- Please take a look and give me some feedback. Thanks. 

,Stefani MeusfJorn , 

:Jie{d' .Jl..aministrator 

SVV 'Region Section 3 

Office: 360-571-4333 

Cere: 360-772-3793 

From: 

Sent: 

To: 

Subject: 

Witten, Dell-Autumn W. (DOC) 

Monday, March 30, 200910:41 AM 

Meusbom-Marsh, Stefani L. (~OC) 

RE: 380 200 Community Supervision of Offenders 

Ralph Berthon owns 380.200. Please, include him as well. 

Thank you! 

From: MeusbQm-Marsh, Stefani L. COOC) , 

Sent: Monday, March 30, 200910:40 AM 

To: Undell, Katrina R. (OOC)i Witten, Dell-Autumn W. (~OC) 

,Subject: PN: 380 200 Community Supervision of Offenders 

Katrina- Since you are the official policy owner on this one, let's take a look at this 

together. Thanks. 

Stifani Jv1.e;usBorn 

PDU-6655-3000086

Jie{a .Jtaministrator 


Office: 360-571-4333 

CerE 360-772-3793 

From: Witten, Dell-Autumn W. (DOC) 

Sent: Monday, March 30, 2009 8:53 AM 

To: ,'Meusborn-Marsh, Stefani L (DOC) , 

Subject: fIN: 380 200 Community Supervision of Offenders 

Hi Stefani: 

More questions on this draft. Please let me know where this information hClS been moved 

to or if it was removed as redundant: 

I 

Violations -- I have, a note that this language was going to be moved to DOC 320.145 

Violator Confinement in Department Facilities, but it hasn't been yet. It should not be 

removed until it gets moved to 320.145. 

Community Supervision of High Risk Offenders -- Since 380.100 was in Annual 

Review, this policy needs to be processed now. If this was removed on account of 

Risk Management.Teams and they have not been disbanded yet, the language 

should stay in. 

I also' have notes that language from DOC' 380.250 GENIE/KIOSK Use in Offender 

Supervision should be added to this policy so that one can be rescinded. I suggest 

'~dding it under Offender/Collateral Contacts. Let me know if you concur. 

' 

E. KIOSK reporting may be used in the following 

circumstances: . 

.:t-:. 

To supplement, but not replace, in-person reporting. 

for High and Moderate Risk offenders and Low Risk 

offenders required to register. 

2. Low Risk offenders not 'required to register will report 

to KIOSK and be primarily managed using 

GENIE/KIOSK resources. 

3. DO$A offenders may report to KIQSK, but will also 

have weekly in-person contact until admitted to 

chemical dependency treatment. 

I' 

4. , For enhanced reporting requirements for homeless 

offenders. 

5. GENIE/KIOSK may be used as a supervision .. 

enhancement to monitor legal financial payments and 

to assist with the scheduling and notification of 

urinalysis testing requirements. . 

PDU-6655-3 000087

Let me know if you have questions for me, 

Thank you! 

From: Witten, Deli-Autumn W. (DOC) 

Sent: Friday, March 2,7, 2009 3:05 PM 

To: . Meusborn-Marsh, Stefani L. (DOC) 


Hi Stefani: 

Quick Question - Regarding offender supervision, has the content on inactive 

Administrative Phases A and B been·moved to the CCO manual, or has it gone away 

entirely 

Please let me know, 

Thank you!· 

From: McKenzie, Jane M. (DOC) On Behalf Of Lindell, Katrina R. (DOC) 

Sent: Friday, March 13, 2009 3:23 PM . 

To: Witten, Dell-Autumn W. (DOC); Meusbom-Marsh, Stefani L. (DOC) 

Cc: Lindell; Katrina R. (DOC) . . 

Subject: FW: 380 200 Community Supervision of Offenders . 

Autumn, Katrina has reviewed and approved the below policy that has incorporated 

380.100. There are some formatting issues bLlt am not sure if you want me to do that or 

not. Please let me know. Thanks, Jane . 

From: Miller, Merlin K. 'Lin' (DOC) 

Sent: Tuesday, February 17, 2009 8:56 AM 

To:' Lindell, Katrina R. (DOC) 

Cc: Meusborn-Marsh, Stefani L. (DOC) 


. Katrina/Stef, a couple more ~ommerits made in red in the attached. 

. . . . 

(Stef, I know how you feel about the.·policy, now just want to it PONE.) 

From: Meusborn-Marsh, Stefani L. "(DOC) 

Sent: Friday, February 13, 2009 2:22 PM 

To: Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC); Miller,.Merlin K. 'Lin' 

(DOC); McKenzie, Jane M. (DOC) 

Subject: 380 200 Comml\nity SuperVision of Offenders 

«File: 380200 Community Supervision OfOffenders.doc» Katrina - Here 

is the policy after having gone through my simplification and run past the union, the policy 

owner, Lin an'd the RA's for comment. . I have also combined this with 380.100 Offender 

Supervision Status. So that policy will no longer exist. There was discussion about the 

Medicinal Use of Marijuana being included in this policy - I really do not think it belongs 

here, but am not sure just where is should gothis is the policy the AS put it in so I left it 

here. In the future when the annual review is done, maybe there should be some 

consideration of placing it in the 320.155 Violation Policy Also the other area that 

causes eyebrows to lift is the Duty Officer Coverage sectionit really does not belong in 

this policy but where does it belong. Lin suggested 370.100- unfortunately, that policy is 

just being developed. . 

PDU-6655-3 000088

Autumn- This is on to you - I am keeping all of my notes for reference on this one. 

Please also see the above as you may want to switch some things around. 

Lin- Please take one last look t6 make sure "this all makes sense, please .............it is all 

running together on me now. 

, 1 

i 

PDU-6655-3 000089

Interpretation of Medical Marijuana ~se 

Page 1 of2 

.From: Berthon, Ralph M. (DOC) 

Sent: Friday, April 17, 2009 6:42 PM 

To: Wheeler, Judine L. (DOC) 

Subject: FW: Interpretation of Medical Marijuana use 

. This may be necessary for the disclosure request 

From: Brink, Benjamin L. (~OC) 

sent: Monday, April 13, 2009 4:23 PM 

To:' Berthon, Ralph M. (~OC) 

Subject: RE: Interpretation of Medical Marijuana use 

I just called Judi and told her that it's your turn to cali. I called when you were out at a doctor's appt. 

From: Berthon, Ralph M. (~OC) 

Sent: Monday, April 13, 2009 3:38 PM 

To: Brink, Benjamin L. (~OC) 


No you call me. 


Sent: Monday, April 13, 200910:24 AM 


Subject: FW: Interpretation of Medical Marijuana use 

tried to call you about this. give me a qall back sometime today. 


Sent: Friday, April 10, 2009 8:42 AM 


SUbject: RE: Interpretation of Medical Marijuana use 

this can wait until you're back at work. I don't want to bother you on your death bed. 

From: Berthon, Ralph M. (~OC) 

Sent: Thursday, April 09, 2009.11:04 AM 

To: Brink, Benjamin L. (Ooq 


cali me on the company cell 


Sent: Thu 4/9/2009 10:45 AM 


. Subject: Interpretation of Medical Marijuana use' 

. . 

Ralph, 

I've had this question asked from time to time and it's being asked again: what do we do with 

. offenders who have already been provided a medical marijuana card and their use.of marijuana 

PDU-6655-3 000090 

5/13/2009

Interpretation of Medical Marijuana use 

Page 2 of2 

The policy and AB speak to offenders requesting to use medical marijuana and their request to get 

it. However, the policy does not address what to do if we get an offender on supervision who is 

ALREADY using marijuana per some kind of other referral. 

My case involves an offender'named~ho was recently sentenc'ed and is in 

custody at this time where we revoke~ded a copy of the Marijuana c:ard 

when my staff arrested him and searched his home. YVe took all of his smoking devices .into 

evidence. 

I 

Like.lmention above, policy is VERY clear on what to do when someone wants to use THe, but it is 

not clear about what to 'do when we get the caselintake where they are already using it. 

Thanks for the help. 

5/13/2009 

PDU-6655-3 000091

From: 

Sent: 

To: 

Duggan, Brenda J. (DOC) 

Wednesday, April 15, 20099:41 AM 


Cc: Allum, Gerald V. (DOC) , 

Livingston - Cannabis Defense Coalition 

Worked on obtaining information from 

Offender Location at Oc'curence: N/ A 

Date & Time of Occurence: 03/25/2009 

DOCNo. ______ 

OffenderName:_ 

Author Name: Jodery Goble 

Events: Field Offender (FP ) I MET WITH P AT THE KLICKITAT COUNTY JAIL 

LIBRARY TODAY(03/25/2009) AT APPROX. 1030-1139 HOURS. P RECENED HIS 

INTAKE PAPERWORK AND MR TO COMPLETE. P CLAIMED HE HAS 

TROUBLE WITH READING AND WRITING. I GA VB P MY ~USINESS CARD. I 

OJ;1FERED P THE PREA INFORMATION. P DID NOT WANT TO TAKE THE 

BROCHURE:P'S CONDITIONS, REQUIREMENTS, AND INSTRUCTIONS; AND 

CONSENT FOR DRUG/ALCOHOL TESTING (FIELD) FOR BOTH THE FELONY 

AND MISDEMEANOR CAUSES WERE REVIEWED, DISCUSSED, AND SIGNED. I 

TOLD P, THAT I WOULD MAKE HIM A SET OF COPIES FOR HIS RECORDS , 

AND LEA VB THEM WITH THE JAIL STAFF. THE JAIL STAFF WILL GIVE P THE 

DOCUMENTS. NOTE: I MADE A CORRECTION TO THE FELONY CONDITIONS: 

P IS NOT REQUIRED PER THE J&S TO OBTAIN A DRUG/ALCOHOL 

EVALUATION AND FOLI"OW THROUGH WITH ANY RECOMMENDED 

TREATMENT. I CROSSED THIS OUT AND INITIALED THIS. P ALSO INITIALED 

THIS CHANGE. P CLAIMED HIS RELEASE DATE FROM THE KLICKITAT 

, COUNTY JAIL IS 03/3112009 AT 2104 HOURS. NOTE: I CONFIRMED THIS DATE 

WITH THE JAIL ST AFF(EMME). P IS A W A.RE THAT HE WILL BE REQUIRED TO 

'REPORT TO THE GOLDENDALE DOC OFFICE ON 04/01/2009. I TOLD P THAT, 

HE WOULD BE CHECKING IN WITH ANOTHER OFFICER ON 04/01/2009, SINCE 

I WOULD NOT BE IN THE DOC OFFICE ON 04/01/2009. P WANTED TO DISCUSS 

THE MEDICAL MARIJAUNA ISSUE. P CLAIMEP HE HAS A MEDICAL 

,MARIJUANA CARD. I EXPLAINED THAT SINCE HE IS UNDER SUPERVISION 

WITH DOC, HE WOULD NEED THIS APPROVED BY THE DOC DOCTOR AFTER 

P'S DOCTOR COMPLETED THE DOC P APERWORKFOR MEDICAL 

MARIJAUNA. P IS AWARE, THAT GETTING APPROV A.L FOR USING MEDICAL 

MARIJAUNA IS NOT EASY. I DID POINT OUT, THAT P COULD GET A 

MERINOL PRESCRIPTION ANDTHIS WOULD NOT NEED THE DOC DOCTOR'S 

APPROVAL. P CLAIMED HE HAS HAD A MERINOL PRESCRIPTION IN THE 

PAST, BUT HE FELT THE 

BETTER. P GAVE 

ME HIS PHYSICAL W A 98620; 

MAILING WA 98620; PHONE # 

I DID WRITE P'S ,APPTS. DOWN ON THE BUSINESS CARD. P IS 

ALSO REQUIRED TO REPORT IN PERSON AT THE GOLDENDALE DOC OFFICE 

ON 04/06/2009 AT 10:30AM. I THANKED P FORRIS TIME AND HE LEFT THE 

PDU-6655-3000092

LIBRARY. NOTE: P MENTIONED HE SELLS HIS FLOWERS AND VEGETABLE 

PLANTS AT THE SATURDAY MARKET IN GOLDENDALE. P OFFERED TO 

SELL ME SOME OF THE FLOWERS ETC. I MADE IT CLEAR WITH P, THAT I 

COULD NOT BUY ANY FLOWERS ETC. FROM HIM, BECAUSE HE WAS UNDER 

SUPERVISION WITH DOC. 

Date & Time Created: 04/011200910:28 AM 

Offender Location at Occurence: NIA 

Date & Time : 04/0112009 . 


Author Name: Brenda Duggan 

Events: Office Offender ( OP ) P reported into the Goldendale field office and proVided 

myself a copy of Documentation of Medical Authorization to Possess Marijuana for 

Medical Purposes. I asked P ifhis assigned CCO has given him the paperwork that needs 

to be filled out to receive DpC authorization to use ·the marijuana and he stated he had 

. not. I provided P wiattha copy of Form # 14-053 and explained the process and timelines 

with P he agreed to follow them and not to use Marijuana until he was authorized to do 

so. 

& Time Created: 04/14/2009 02:49 PM 

Offender Location at Occurence: NI A 

Date & Time of Occurence: 04/09/2009 

DOC No. 


Author Name: Jodery Goble 

Events: 10 day home visit ( ZH ) CCO NIELSEN AND MYSELF(CCO GOBLE) 

CONDUCTED A i 0 DAY HOME VISIT ON P TODAY(04/09/2009) AT APPROX. 

1454-1601 HOURS. WHEN WE ARRIVED AT P'SADDRESS, THERE WERE AT 

LEAST 3 PEOPLE(INCLUDING P) MOVING TREE SAPLINGS OUT OF A BOX IN 

THE BACKOF A PICKUP TRUCK AND MOVING THEM INTO THE BARN. I 

ASKED P TO SHOW ME WHERE HE IS SLEEPING. P SAID, HE WAS SLEEPING 

IN THE BARN, BUT HAS MOVED TO THE CAMPER, BECAUSE IT IS TOO 

WARM IN mE BARN. I WALKED AROUND THE BARNTO THE NORTH. 

THERE WAS A PICKUP CAMPER ON SITE. P SHOWED ME AROUND IN THE 

CAMPER. IT APPEARED NO ONE HAD BEEN SLEEPING IN THE CAMPER. NO 

VIOLATIONS WERE OBSERVED. I ASKED P TO SHOW ME WHERE HE HAD 

BEEN SLEEPING IN THE BARN. P LED ME THROUGH THE LOWER LEVEL OF 

. THE BARN AND THEN UPSTAIRS IN THE BARN. CCO NIELSEN WAITED 

DOWNSTAIRS. ONCE UPSTAIRS P POINTED OUT HIS BED AND THEN P. 

WALKED INTO THE ADJoiNING ROOM. I IMMEDIATELY NOTICED 

MARIJUANA PLANTS. I ASKED P WHAT WAS GOING ON. P CLAIMED THAT 

THERE WAS A PERMIT TO GROW THE MEDICAL MARIJUANA. P SHOWED ME 

THE PERMIT ON THE WALL. I TOLD P, THAT UNDER HIS· CONDITIONS OF 

SUPERVISION HE COULD NOT BE AROUND THE MARIJUANA. I ASKED CCO 

PDU-6655-3 000093,

NIELSEN TO COME UPSTAIRS. CCO NIELSEN WENT INTO THE ROOM, WHILE 

I WATCHED P. P WAS HOLDING A SMALL KNIFE IN A NON THREATENING 

MANNER. P THEN PUT THE KNIFE DOWN. CCO NIELSEN CALLED THE 

KLICKITAT COUNTY SHERIFF'S OFFICE DISPATCH AND REQUESTED A 

DEPUTY BE DISPATCHED TO OUR LOCATION. WE WENT DOWN TO THE 

GREEN HOUSE WHERE P MENTIONED THERE WERE MORE PLANTS. WE 

CHECKED OUT THE GREEN HOUSE. WE OBSERVED MORE MARIJUANA 

PLANTS. THERE WERE ALSO 4 MORE PERMITS FOR MEDICAL MARIJUANA 

ON THE WALL IN THE GREEN HOUSE. WE WENT OUTSIDE AND WAITED FOR 

THE DEPUTY. P'S BROTHER AND SISTER-IN-LAW WERE STARTING TO GET 

UPSET. AT APPROX. 1515 HOURS, UNDER SHERIFF(ERIK 

ANDERSON)ARRIVED ON SITE. THE UNDER SHERIFF STARTED HIS 

INVESTIGATION. THE UNDER SHERIFF TOOK PHOTOGRAPHS OF THE 

PLANTS AND PERMITS. THE UNDER SHERIFF ALSO READ P HIS RIGHTS. TaB 

UNDER SHERIFF TOLD US THAT THE PERMITS WERE VALID AND THAT 

THEY WERE NOT GROWING ANY MORE MARIJAUNA THAN ALLOWED. CCO 

NIELSEN AND I DISCUSSED THE ISSUE WITH P. SINCE P IS IN THE PROCESS 

OF TRYING TO GET HIS MEDICAL MARIJUANA USE APPROVED BY THE DOC 

DOCTOR, WE WILL NOT ARREST HIM FOR POSSESSION OF A CONTROLLED 

SUBSTANCE AT THIS TJ:ME. ITOLDP, IF HIS UA WAS DIRTY HE WOULD BE 

IN VIOLATION AND MAY BE ARRESTED. P CLAIMED THE UA WILL BE 

CLEAN. WE COMPLETED THE HOME VISIT IN THE MAIN RESIDENCE. P 

SHOWED ME THE COMMON AREAS. P CLAIMED THAT ALL THE FIREARMS 

WERE SECURE IN A GUN SAFE. P CLAIMED HE HAS TALKED WITH HIS . 

BROTHERS ABOUT THE FIREARM ISSUE. ALSO, P'S BROTfIER CLAIMED 

THEY WILL PUT A DOOR ON THE ROOM WHERE THE MARIJUANA IS 

GROWN. THE DOOR WILL BE LOCKED AND P WILL NOT HA VB A KEY. I 

TOLD P, THAT WE WOULD BE OUT LATER(MAYBE NEXT WEEK) TO CHECK 

ON THIS. WE LEFT THE RESIDENCE TO RETURN TO THE GOLDENDALE DOC 

OFFICE. NOTE: I CALLED MY SUPERVISOR(G. ALLUM) AFTER I RETURNED 

TO THE GOLDENDALE DOC OFFICE. THE TIME WAS APPROX. 1629-1632 

HOURS. I LEFT A MESSAGE ON MY SUPERVISOR'S CELL PHONE. I UPDATED· 

MY SUPERVISOR ON THE HOME VISIT AND THAT THIS SITE WOULD NEED A 

HOME VISIT NEXT WEEK TO MAKE SURE THE MEDICAL MARIJUANA HAS 

BEEN SECURED 

I 

I 

Brenda.J. Duggan 

Secretary Senior/Assignment Officer 

Goldendale Field Office 

228 S. Columbus, Suite .1.03 

. Goldendale, W A 98620 

509-773-3708 

509-773-5230 Fax 

PDU-6655-3 000094

From: 

Sent: 

To: 

Duggan, Brenda J. (DOC)" 

Wednesday, April 15, 2009 9:37 AM 


Cc: Allum, Gerald V. (DOC) , 

RE: 

ivingston - Cannabis Defense Coalition 

- Worked on obtaining information from 

9:22 a.m. to 9:35 a.m. 

Offender Location at Occurence: N/ A 

Date & . 11/17/2008 


Offender 

, Author Name: Ronda Nielsen, , 

Events: Field Offender ( FP ) MET WIMR~T THE KLICK.CO.JAIL. 

WENT OVER J &S CONDITIONS, HE HAD QUESTION ABOUT COS FEES, 

ANSWERED THAT QUESTION. WANTED TO KNOW WHY AND IF HE NEEDED, 

TO DO DV EVALUATION & FOLLOW UP TX AS DIRECTED. TOLD HIM I ' 

BELIEVE IT IS BECAUSE HE WAS ORIGINALLY CHARGED WITH AN 

ASSAULT DV. AND TOLD HIM HE WILL HAVE TO DO IT, BECAUSE THAT IS 

WHAT THE COURT ORDERED. READ THROUGH HIS DOC CONDITIONS, 

REQUIREMENTS & INSTRUCTIONS FORM, DRUG/ALCOHOL TESTING 

INSTRUCTIONS, AND RLS OF INFORMATION. HE SIGNED ALL 3 DOCUMENTS 

ACKNOWLEDGING HIS UNDERSTANDING & AGREEMENT TO COMPLY. MR.: 

_STATED HE JUST GOT HIS LEGAL MEDICAL MARIJUANA CARD 

UPDATED. TOLD HIM THERE IS A PROCESS HE MUST GO THROUGH TO BE 

r ABLE TO LEGALLY USE MARIJUANA WHILE ON SUPERVISION. WILL BRING' 

HIM THENECESSARY FORMS TO SIGN WHEN I SEE HIM NEXT, BEFORE HE 

IS RELEASED FROM JAIL. ' ' , 

& Time Created: 12/09/2008 11 :02 AM 

Offender Location at Occurence: N/ A 

Date & Time ofOccurence: 12/09/2008 

DOC No'; 

Offender 

Author Name: Ronda Nielsen 

, Events: Office Offender ( OP ) TED TO DOC IN 

GOLDENDALE AFTER BEING RELEASED FROM JAIL ON 12/8/08. HE FILLED 

OUT A MR FORM. I PROVIDED HIM WITH FORM TO SEND TO HIS PRIIViARY 

PHYSICIAN TO FILL OUT REGARDING MEDICAL MARIJUANA. TOLD HIM IT 

WAS HIS REsPoNs.mILITY TO GET THIS FILLED OUT ASAP. HE INDICATED 

HE WOULD CALL HIS PHYSICIAN GET THE PROCESS STARTED. I 

INSTRUCTED HIM TO REPORT TO DOC IN GOLDENDALE ON 12/15/08 AT 

3:00PM, WILLCONDUCTONAINTERVIEW AT THAT TIME. WAS GOING TO 

DO IT TODAY, HOWEVER :MR._INDICATED HE HAD A WATER 

LEAK AND WATER WAS ALL OVER HIS FLOORING IN HIS RESIDENCE. 

PDU-6655-3000095

Date & Tirpe Created: 12/16/2008 11 :40 AM 


Date & Time ofOccurence: 12/11/2008 10:18 AM 



Events: Telephone Collateral ( TC ) RCVD VOIc::::EMAIL MSG LEFT BY RICK 

W/HEMP-CANNABIS FOUNDATION. REQUESTED RETURN PH CALL AT (425) 

999-1911, RE: MR. FOR PRESCRIPTION FORMARINOL. 

12115/200804:12 PM 


Date & Time 12/15/2008 

DOC 


Author Name: ROilda Nielsen 

. Events: Office Offender ( OP ) MR._REPORTED TO DOC IN . 

GOLDENDALE TODAY AS INSTRUCTED. CONDUCTED ONA INTERVIEW. 

DISCUSSED MARIJUANA ISSUE, HAS APPT WITH DOCTOR IN BELLEVUE, 

LOOKING FOR MARINOL PRESCRIPTION WHILE HE IS ON SUPERVISION. AS 

HE HAS MEDICAL MARIJUANA AUTHORIZATION, BUT HAS BEEN 

INFORMED THAT PAPERWORK NEEDS TO BE COMPLETED BY BOTH HIS . 

PRIMARY PI1YSICIAN AND DOC, HE IS GOING TO TRY· SOMETHING 

DIFFERENT. I ISSUED HJ;M AN IN-STATE TRAVEL PERMIT TO BELLEVUE WA 

ON 12118/08 AND ALSO ISSUED HIM AN OOS TRAVEL PERMIT TO THE 

DALLESIHOOD RIVER OREG. FOR SHOPPING. PERMIT VALID FOR SAME DAY 

TRAVEL ONLY, NO OVERNIGHT STAYS ALLOWED FROM TODAY -116/09. I 

INSTRUCTED HIM TO REPORT TO DOC IN GOLDENDALE ON 116109 ANY TIME 

BETWEEN 8-4:30PM, EXCEPT 12-1PM. 


Date & Time ofOccurence: 01106/2009 

DOC No.:_ 

.. Offender Name: iii ••••••• 

Author Name: Ronda Nielsen . 

Events: Office Offender ( OP ) MR. ~REPORTED TO DOC IN 

GOLDENDALE TODAY AS INSTRUCTED. FILLED OUT MR FORM, NO 

VIOLATIONS OR CHANGES REPORTED. UA TAKEN, PACKAGED & PLACED 

. IN OUTGOING MAIL. ADMITTED TO SMOKING MARIJUANA YESTERDAY. 

HAS APPT WITH HIS THC DOCTOR IN BELLEVUE ON 118/09, IS GOING TO 

REQUESTING SYNTHETIC FORM OF MARIJUANA WHILE HE IS ON 

SUPERVISION. I PROVIDED MR._WIREFERRAL TO TSI FOR HIS 

PDU-6655-3 000096

DV ASSESSMENT TO BE COJv1PLETED WITHIN 30 DAYS OF THE REFERRAL. I 

ISSUED HIM AN OOS TRAVEL PERMIT TO THE DALLESIHOOD RIVER OREG 

FOR SHOPPING. PERMIT VALID FOR SAME DAY TRAVEL ONLY, NO 

OVERNIGHT STAYS ALLOWED FROM TODAY - 2/3/09. I ALSO ISSUED HIM AN 

IN-STATE TRAVEL PERMIT TO BELLEVUE W A ON 118109. DUE TO PASS 

CONDITIONS, WItL BE GOING THROUGH GORGE AND UP 1-5 IN W A. I 

INSTRUCTED MR. THOJv1PSON TO REPORT TO DOC IN GOLDENDALE ON 

2/3/09 ANY TIME BETWEEN 8-4:30PM, EXCEPT 12-1PM. 

Date & Time Created: 01/12/2009 04:30 PM 

Offender Location at Occurence: N/A 

Date & 01112/2009 

DOC No.:' 


Author Name: .==~=~ 

Events: Office Offender ( OP) MR.~AME INTO DOC OFFICE IN 

GOLDENDALE REQUESTING 3RD IN-STATE TRAVEL PERMIT TO BELLEVUE 

TO VISIT HIS CANNABIS DR. PERMIT ISSUED FOR 1116/09. 

; , . 

Date & Time Created: 01114/2009 09:01 AM 


Date & 

01113/200911:18 AM 



Author Name: ~~~=!!.. 

Events: Home Offender (HP ) WICCO GOBLE. MET WITH MR. _AT . 

. HIS RESIDENCE, GAVE CCO TOUR OF RESIDENCE. HE HAS DONE SOME 

GOOD REMODELING, LAYING CARPET, WOOD FLOOR, PLACE WELL KEPT 

UP. NO VIOLATIONS REPORTED OR SEEN. MR.~AS APPT IN 

BELLEVUE SCHEDULED FOR THIS WEEK; GOING TO REQUEST' 

PRESCRIPTION FOR MARINOL FROM HIS DOCTOR 

I 

l' 

Date & Time Created: 01/15/2009 03:38 PM 

. Offender Location at Occurence: NI A 

Date & Time ofOccurence: 01/15/2009 


Offender 


Events: Telephone Collateral ( TC ) RETURNED RICK'S PH CALL FROM 

HEJv1P/CANNABIS FOUNDATION. REPORTEDLY MR~ 

TOLD HIM 

THAT I HAD REQUESTED THE DOCTOR PRESCRIBE HIM MARINOL. DOCTOR 

"TURNED HIM DOWN FLAT" BECAUSE HE THOUGHT ceo WAS 

REQUESTING. I INFORMED RICK THAT WAS NOT THE CASE. I HAD 

EXPLAINED PAPERWORK THAT NEEDED TO BE DONE THROUGH MR. 

PDU-6655-3 000097

PRIMARY CARE PHYSICIAN AND LOOKED OVER 'BY DOC 

AND THEN EITHER APPROVED OR DENIED. I DID INFORM MR. 

T THERE IS A VALID PRESCRIPTION FORMARINOL THAT 

HE COULD POSSffiLY TALK TO HIS DOCTOR ABOUT PRESCRmING TO HIM 

AND THAT IS WHEN HE SET UP APPT W/THEIR FOUNDATION. MR. . 

~PPT IS SET FOR 1116/09 AT 12:00PM. THANKED HIM FOR THE 

INFORMATION. 

Date & Time Created: 0112112009 10:24 AM 


. Date & Time 01120/2009 



Author Name: ~~~=~ 

Events: Telephone Collateral ( TC ) RCVD PH CALL FROM MR. , HE 

INDICATED HE WAS PRESCRmED THE MEDICATION BY HIS CANNABIS 

, DOCTOR. HAS ALSO REQUESTED TO BE ON THE PROBATION HRG DOCKET 

SET FOR 2/6/09 AT 9:30AM. IS REQUESTING HIStFO'S BE CONVERTED TO ' 

CSH. HAS ,REPORTEDLY ALREADY STARTED CSH WITH FOOD BANK IN 

ANTICIPATION OF CONVERSION. 

Date & Time Created: 011211200911:41 AM 


Date & Time of Occurence: 01121/2009 

DOC 'V" 1 __ 



Events: Office Offender ( OP ) MR._BROUGHT IN CoPy OF DRUG 

PRESCRIPTION AND LIST OF ALL THE MEDICATIONS HE IS CURRENTLY 

TAKING. PLAC~D IN FIELD FILE 

I 

BrendaJ. Duggan 

Secretary Senior/Assignment Officer 

Goldendale Field Office 

228 S. Columbus; Suite 103 

Goldendale, W A 98620 

509-773-3708 

509-773-5230 Fax 

From: 

Sent: 

Allum, Gerald V. (DOC) 

Tuesday, April 14, 2009 7:11 AM 

PDU-6655-3 000098

I, 

I 

I , , 

THCF ,Medic'al Clinics 

1813 130 th Ave .. , NE #210, 

Bellevue" WA 98005 

Phone: 425~869~6186 or 800~ 7'23~0188 

Fax: 425~869~6378 

www.thc~foundation.org 'www,hemp.org_ 

Documentation of Me

Distefano, Monica J; (DOC) 

From: 

Sent: 

To: 

Subject: 

Attachments: 

Meusborn-Marsh, Stefani L. (DOC) 

Friday, February 13, 2009 2:22 PM 

Lindell, Katrina R. (DOC); Witten, Dell~Autumn W . (DOC); Miller, Merlin K. 'Lin' (DOC); 

McKenzie, Jane M. (DOC) 

380 200 Community Supervision of Offenders 

380 200 Community Supervision of Offenders;doc 

380 200 Commuriity 

Supervision •••. '. . . . . 

-Katrina - Here is the policy after having gone through my simplification ahd run past the union, the policy 

owner, Lin and the RA's for comment. I have also combined this with 380.100 Offender Supervision Status. So that POlicy. 

will no longer exist. There was discussion about the Medicinal Use of Marijuana being included in this policy - I really do 

not think it belongs here, but am not sure just where is should gothis is the policy the AB put it in so I left it here.' In the 

future when the annual review is done, maybe there should be sQme consideration of placing it in the 320.155 Violation 

Policy Also the other area that causes eyebrows to lift is the Duty Officer Coverage· sectionit really does not belong 

in this policy but where does it belong. Lin suggested 370.100- unfortunately, that policy is just being developed. 

Autumn- This is on to you - I am keeping all of my notes for reference on this one. Please also see the above as you 

may want to switch some things around. 

Lin- 

Please take one last look to make sure this all makes sense, please ............ :.it is all running together on me now. 

1 

PDU-6655-3 000100

380.200 COMMUNITY SUPERVISION OF OFFENDERS 

REFERENCES: 

DOC 100.100 is hereby incorporated into this policy; RCW 9A.44.130; DOC 280.500 

Records Management of Official Offender Files; DOC 380.605 Interstate CQlJlpact, DOC 

420.380 Drug/Alcohol Testing; DOC 460.130 Hearings for Community Custody, Work 

Release and Pre-Release; DOG 320-420 Offender Supervision Plans; DOC 390.600 

Imposed Conditions; DOC 320.155 ViolationProcessNiolations of Conditions 

POLICY: 

1. Community supervision will be performed in a mru:mer that is in the best interest 

·of community safety, based on the offender's risk level and supervision sta,~s. 

DIRECTIVE: 

1. The Community Corrections Officer (CeO) will supervise the offender and 

.complete contacts as appropriate. . 

2. eco's will identify offender needs and address those needs within available 

resources, programs, referrals, and treatment aimed at achieving .successful reentry. 

. 

PROCEDURE: 

1. Offender supervision status 

A. Active supervision is: 

1. when the offender is available for supervision in the community . 

2. for 60 days from the date a warrant for an active cause was issued 

and/or the first 60 days of a total or partial confinement sanction, 

and after a mental health commitment that does not toll 

. supervision. 

B. . Inactive supervision is: 

1. . When the offender is unavailable for supervision and does not 

meet one of the criteria above . 

C. 

. Rfsk level classifications are: 

1. 

2. 

Unclassified 

High Violent 

I· 

I 

PDU-6655-3 000101

3. High Non-Violent 

4. Moderate, and 

,5. Low 

2. Community'Supervision 

A. The CCO has primary responsibility for imposing' or, recommending the 

imposition of, and monitoring of the supervision conditions for offenders 

and, 

' ' 

B. Developing the Offender Supervision Plan. 

3. Medicinal Use of Marijuana 

A. At the offender's request, the ¢CO will provide the offender DOC 14-053 

Medicinal Use of Marijuana Verificatiommd DOC 13-035 Authorization 

for Disclosure of Health Information. 

B. Once'the Medical Director has approved/denied the request, the Assistant 

Secretary for Commuirity Corrections will notify the CCO of the decision.' 

C. The offender'may appeal the decision to the Assistant Secretary for 

Community Corrections who will approve or deny the appeal in 

conjunction with the Assis~ant Secretary for Health Services. 

1. " The appeal will be submitted in writing within 15 days' of written' 

notice of the denial and can only appeal if they inClude additional 

infonnation not previously utilized for the original denial. ' 

2. The Assistant S~cretary will provide a response to the offender 

within 30 days of receipt. 

4. Offender/Collateral Contacts 

A. Complete a home visit to verify the offender's address within 10 days of 

assuming supervision if assuming supervision from aiJ.other unit. 

B. Offenders must report to a CCO as required by risk level classification and 

complete a monthly report. ' 

C. Minimum Contact' standards: 

PDU-6655-3 000102

i·· 

High Risk to. Re-effend - Vielent (HV) • 3 face-te-face/menth (2 efwhich 

D . . . 

are out of the office) 

1 collateral/menth 

High ~k to Re-offend - Non-violent 

• 

2 face-to-face/month (l.efwhich is 

(HNV) . 

e, . 

out efthe effice) 

In 

• 1 collateral/month 

Moder~te Risk to Re-effend (MOD) 

1 fape-t0-face/menth 

1 face-te-face heme er field/quarter 

F 

• 1 cellateral/menth 

Low Risk to. Re-offend - Required to. . 

1 face-to-face/month 

Regist~, Mental Health, RHPP 

• 1 face-to-face home er field/quarter 

particiIl1ants, DOSA first 90 days 

• 1 cellateral/menth 

Lew R&k to. Re-offend 

• Offender reports. changes in status 

via Kiesk 

.c 

• 

HemelSss offenders except RMD/low risk 

. . 

,. 1 face-to.-face/week (in the field if 

with nOlcentacts· possible)· . 

D.Field centacts may be made at any lecation where the offender er 

cellaterals may be feund. 

E. Demonstration of reasonable effort to conduct contacts ~ay count as a 

contact. 

F. Contact standards may be reduced: 

PDU-6655-3 000103

, ' 

~. With Community Corrections Supervisory approval, after 6 

months of compliance and if the offender's progress on 

supen:ision warrants a reduction: ' 

I i 

I 

i 

! 

I 

I 

I 

\ 

i 

2. 

4. 

a. "High and Moderate Risk not required to register", 

standards will not be reduced more than to the next lower 

level of contact standards. 

b. "Moderate and Low Risk" who have miniinum face-to-face 

contact standards may only be reduced for reasons of 

offender availability in the community. 

When the offender is in local custody, in-patient treatment 'or 

otherwise 'not available. 

a. If in local custody over 30 days, the CCO should make 

contact during ,the last 30 days of confinement for release 

planning. . , 

For all reductions in contact standards, staff will update the 

Offender Supervision' Plan and document the reasons for the 

reduction in the electronic file. 

G. Compliance Review 

1. ' Each cause will be reviewed, 3 ,months prior to the scheduled end 

of supervision on that cause using DOC 02-175 M3 Review' 

Checklist, identifying any outstanding violation behavior and 

prepare the cause for supervision closure and summary adjustment. 

5. Duty Officer Coverage 

A. Community Corrections staff will provlde coverage in the office to ensure 

that services are available to offenders and stakeholders. 

B. The Duty Officer, will meet with offenders during the absence of the 

assigned CCO to perform supervisory functions including, but not limited 

to: 

, 1..' Signing standard conditions of supervision, 

2. Obtaining urinalysis (UA), if applicable, 

3. Reviewing reporting instructions, 

4. Obtairung/updating personal information, 

5. Reviewing file,material and/or cowt documents, and 

6. In emergent situations, making arrests, issuing travel permits per 

Department policy and office procedures. 

PDU-6655-3 000104

C. The Duty Officer wili document contacts in the offender's electronic file 

per DOC 280.350 Records Management of Official Offender Files. 

D. The Community Corrections Supervisor will make arrangements for 

coverage if the Duty Officer is not available, to include posting emergency 

contact information for the public and leaving contact information on the . 

office main voicemail system. 

E. Staff will. notify their supervisor/colleagues of absences from work. 

F. When staff are out of the office on scheduled leave for more than a day, 

they will: . 

1. . Leave a voicemail message that includes length of time they will 

be out of the office and contact information for the Duty· Officer. 

2. Activate the "Out of Office" notice on Outlook. 

3.· Designate ·a staff to moriitor their email and handle emergent 

situations. . 

G. When staff are out of the office on unscheduled leave for an extended time 

the CCS will authorize Information Technology to ·reroute the email to 

another. staff. . 

H. The CCS· will re-assign offenders when a CCO has an unexpected, 

extended absence greater than 2 week to ensure continuity of supervision. 

The CCS will assume case supervision until they are re-assigned unless· 

another plan has been developed for coverage. 

1, 

, 

PDU-6655-3 000105


From: 

Sent: 

To: 

Subject: 

Follow Up Flag: 

Flag Status: 

Follow up 

,Red 

Here it is Jane. 

From: 

Sent: 

To: 

Subject: 

Hann, William G. (DOC) 

Wednesday, March 25, 20094:50 PM 

:~'rman 'Win E WOR 

Not sure what he was ql10ting but if an offender complains about his CCO or anything we tell him of the Grievance 

procedures; to get his own proof of compliance, that it is his right to request transfers to other approved residences (all of 

which are in DOC Policies). We just tell them of their optioris and DOC' practices. . " . 

From: 

Sent: 

To: 

Subject: 

Hann, William G. (DOC)' 

Wednesday, March 25, 20094:44 PM 

, There was no proof that he'd received the letter informing him of the denial of "medical marijuana" and his right to appeal it 

(the denial). Without anything documenting he was aware of it the denial (and he may have indeed received it); I gave him 

the benefit of the doubt. 

From: 

Sent: 

To: 

Subject: 

Braverman, Suzann E. (DOC) 

Wednesday, March 25, 2009 9:19 AM 

Date & Time Created: 03/24/200903:10 PM,' 


. Date & Tim!!e!O!flolc~c~ur~e~n~ce~:~0~3/~2~4~/2~009' 


Offender N.ame 

, AuthorName: William-Hann I 

Events: Hearings Officer (HR) Eull.Hearing, 2009-03-24, Snohomish Jail A, Hearirig Officer: Harm,' 

William G, Presenting Officer: Johns, Becky, Assigned CCO: Sajewski, Sandra E 1) Using Controlled 

Substance on 03/03/2009, Cause (AB,AA), Not Guilty, Possessing Alcohol on 03/03/2009, Cause (AB,AA), 

Guilty, CREDIT FOR TIME SERVED, As Directed, Sai:J.ction duration: 13 day(s). OBTAIN APP'T FOR 

CHEM DEPEND EVALW/IB 10 BZ DAYS AND FOLLOW ALL RECS (PROVIDE PROOF TO CCO). 

INCREASED UAS, Weekly, Sariction duration: 30 day(s). Starting on 03/10/2009. REPORT WITHIN 1- 

BUSINESS·DAY. FOLLOW ALL FACILITY RULES. 

Hi Bill, 

Can you please tell me why p was found not guilty of the manjuana use Despite his "perscription" he is not 

PDU-6655-3 000106

---------------_......._...... . 

authorized to use marijuana and we're seeking some clarification here. P came in this morning with quite an 

attitude towards his ceo with all kinds of quotes of:wh~t he can do from this hearing. 

Thank you 

Suzi 

I 

I 

2 

PDU-6655-3 000107

I 

FW: 380200 Community Supervision of Offenders 


'From: 

Sent: 


Thursday, April 02, 2009 11 :17 AM 

. To: Lindell, 'Katrina R. (DOC) . 

Subject: 

Attachments: 380200.doc 

Fw: 380 200 Community SupervisIon of Offenders 

--.----------._-----,--_._-- 


To: Meusborn-Marsh, Stefani L (DOC) 

Sent: Thu Apr 02 11:00:50 2009 


PagC110f4 

Hi Stefani: 

I have made the change Ralph'suggests and added the KIOSK info to facilitate rescinding 380.250, and will work 

with Lin on placing ,the violator information in the 320.145 AB he's drafting. Ralph would like to move medicinal 

marijuana too, and I'll check on that with Lin.. . 

So now I just need to resolve the Community Supervision of High RiskOffenders section. Please advise. 

Thank you! 

From: Berthon, Ralph M. (DOC) 


To: Witten, Dell-Autumn W. (DOC); Meusborn-Marsh, Stefani L (DOC) 

Subject: FW: 380 200 Community Su'pervision of Offenders 

Folks, 

I really cannot tell you how many times I have seen this policy or who all'have sent it to me for review inthe past 

year. I am 'excited (I hope it doesn't show!) to see· we are close to putting it to bed. I have read this version and . 

made one minor change that I can li'Ze with or without. It has to do with the ten day contact rule. I added a couple 

of words in regard to intakes as it is not captured in the ihtake policy 310.100. 

In regard to Autumn's remarks below, I can see adding the KIOSK language because it directly applies to . 

supervision on a global scale. 

As for the violations language, we need to take it out and do an AdJTlin Sulleting (AS) to the violations policy. In 

this case the violation data can be captured in an AB, the new 380.200 can go out, when the violation policy gets 

are-write we.add the AS data and we are all happy. Well almost all of us. And of course the same logic applies to 

the Community Supervision of high Risk offender's piece; take it out, put it into and AS and be done with it. 

The medical marijuana piece; that too belongs in a violation policy as it related directly to the process for 

establishing credibility to violate someone. in that there is an AB already out on marijuana, we could amend that 

bulletin and re issue it and tie it to the violation policy. 


I do not want to ruffle feathers, and it may be showing a bit but one area that I feel strongly is these are easy fixes 

to a difficult process of re-writing policies. I will admit that having AS's come out all the time seems to makes' us 

look a litHe diSjointed and lacking in direction, but it is what it is. From one persons perspective it is not a good 

5/13/2009 

PDU-6655-3 000108


Page 2 of4 

enough reason to have policies constantly changing or in "draft" status for months/years while stuff is pending a 

change in another policy; or to issue a policy knowing we wil)have to re write it again and then just not getting to it 

for a year or more. If we are planning any policy change then let's shoot for making it a singular one time fix to a 

policy instead of having to re-write one policy every time we re-write another policy. 

Ralph 



To: Berthon, Ralph M. (DOC) 

Subject: .FW: 380 200 Community Supervision of Off~nders 

«380200.doc» 

. Here you go. Let me know if you have questions. Thal"\k you! 

From: Meusbom-Marsh, Stefani L. (DOC) 

Sent: Monday, March 30; 2009 10:43 AM. 

To: Berthon, Ralph M. (DOC); Witten, Dell-Autumn W. (DOC) 


Ralph- Please take a look and give me some feedback.. Thanks. 

Stefani :M.eus6orn 

jFieU{j\cC~ututrator 

SVV Region Section 3 

Office: 360-571-4333 

Ce{(: 360-772-3793 

From: Witten, Dell-Autumn W.(DOC) 


To: Meusborn-Marsh, Stefani L. CDOC) 


Ralph Berthon owns 380.200. Please include him as well. 

Thank you! 

From: Meusborn-Marsh, Stefani L. (DOC). 

Sent: Monday, March 30; 2009 10:40 AM 

To: Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC) 

Subject: FW: 380 200 Community Supervision of Offenders . 

Katrina- Since you are the official policy owner on this one, let's take a look at this together. Thanks. 

Stefani :M.eus6orn 

:JieCt£ j\cC~inutrator 

5/13/2009 

PDU-6655-3 000109

FW: 380200 COInmunity Supervision of Offenders 

Page 3 of4 


Office: 360-571-433~ 

Ce{[: 360-772-3793 



To: Meusborn-Marsh, Stefani L (DOC) 


Hi Stefani: 

More questions on this draft. Please let me know where this, information ha~ been moved to or if it was 

removed as redu'ndant: 

Violations - I have a note that this language was going to be moved to DOC 320.145 Violator 

Confinement in Department Facilities, but it hpsn't been yet. It should not be removed until it gets 

moved to 320.145. 

Community Supervision of High Risk Offenders -- Since 380.100 was in Annual Review, this policy 

needs to be processed now. If this was removed on account cif Risk Management Teams and they 

have not been disbanded yet, the language should stay in. 

I also have notes that language from DOC 380.250 GENIE/KIOSK Use in Offender Supervision should be 

added to. this policy so that one can be rescinded. I suggest adding it under Offender/Collateral Contacts. 

Let me know if you concur. 

E. KIOSK reporting may be used in the following circumstances: 

1. To supplement, but not replace, in-person reporting for High and Moderate Risk 

offenders and Low Risk offender's required to register. . 

i 

~ Low Risk offenders not required to register will report to KIOSK and be primarily 

managed using GENIE/KIOSK resources. 

3. DOSA offenders may report to KIOSK, but will also have weekly' in-person contact until 

admitted to chemical dependency treatment 

4. For enhanced reporting requirements for homeless offenders. , , 

5. GENIE/KIOSK may be used as a supervision enhancement to monitor legal financia,l 

payments and to assist with the scheduling and notification of urinalysis testing requirements. 


Thank you! 

From: Witten, Deli-Autumn W. (DOC) 

Sent: Friday, March 27, 2009 3:05 PM 

To: Meusborn-Marsh, Stefani L. (DOC) 


Hi Stefani: 

5/13/2009 

PDU-6655-3 000110

FW: 380 200 Community Sppervision of Offenders 

Page 4 6f4 

Quick Question - Regarding offender supervision, has the content on inactive Administrative Phases A ahd ' 

B been moved to the CCO manual, or has it.gone away entirely ' . 


Thank youl 

From: McKenzie, Jane M. (DOC) On Behalf Of Lindell, Katrina R. (DOC) 


To: Witten, Dell-Autumn W. (DOC); Meusborn-Marsh, Stefani L. (DOC) 

Cc:. Lindell, Katrina R. (DOC) 

Subject: , FW: 380 200 Community Supervision of Offenders 

Autumn, Katrina has reviewed and approved the below policy that has incorporated 380.100. There are 

some formatting issues but am not sure if you want me to do that or not. Please let me know. Thanks, 

Jane 

I, 


Sent: Tuesday, February p, 2009 B:S6 AM 

To: Lindell, Katrina R. (DOC) 

Cc: Meusborn-Marsh, Stefani L. (DOC) 

Subject: FW: 3BO 200 Community SupervIsion of Offenders ' 

Katrina/Stef, a. couple more comments made in red in the attached. 

(Stef, I know how you feel about the policy, now just want to it DONE.) 

From: Meusborn-Marsh, Stefani L. (DOC) 

Sent: FridaY,·February 13, 2009 2:22 PM 

To: Lindell, Katrina R. (DOC); Witten, Dell-AutumnW. (DOC); Miller" Merlin K. 'Lin' (DOC); McKenzie, Jane 

M. (DOC)' , 

Subject: 380 200 Community Supervision of Offenders 

«File: 380 200 Community Supervision of Offenders. doc » Katrina - Here is the policy after 

having gone through my simplification and run past the union, the policy owner, Lin and,the RA's for 

comment. I have also combined this with 380.100 Offender Supervision Status. So that policy will no 

longer exist. There was discussion about the Medicinal Use of Marijuana being included in this policy - I 

really do nof think it belongs here, but am not sure just where is should gothis is the policy the AB put it in 

so I left it here. In the future when the annual review is done, maybe there should be some consideration 

of placing it in the 320.155 Violation Policy Also the other area that causes eyebrows to lift is the Duty 

Officer Coverage sectionit really does not belong in this policy but where does it belong. Un suggested 

370.100- unfortunately, that policy is just being developed. 

Autumn- This is on to you - I am keeping all of my notes fat reference on this one. Please also see the 

above as you may want to switch some things around. 

Lin- Please ta'ke o'ne last look to make sure this all makes sense, please .............it is all running together 

oome now. 

5/13/2009 

PDU-6655-3 000111


· From: 

Sent: 

To: 

Subject: 

Follow Up Flag: 

Flag Status: 

Adams, Karen P. (DOC) 

Tuesday, April 14, 2009 9:28 AM 

McKenzie, Jane M. (DOC) 

. FW: Heads up! Medical Marijuana Issue 

Follow up 

Red 

Jane 

Per your request.. .here is something I have on the medical marijuana issue. 

· Karen 

From: Adams,. Karen P. (DOC) . 

Sent: 

Tuesday, November 06, 2007 11:48 AM 

To: 

Randal Enders (E-mail); Miller, c,:heryl S.; Christopher Glans (E-mail); Holmes, Andrea D.; James Yourkoski 

(jmyourkoski@DOC1.WA.GOV); Kenneth Pinkerton (E-mail); Wick, Judy A. (DOC); Elkins, Elaine M. (DOC) 

Subject: 

FW: Heads up! Medical Marijuana Issue . 

FYI 

Karen 

----Original Message----- 

From: 

Freeman, Gregg P. (DOC) 

Sent: . 


To: 

Lindell, Katrina R. (DOC); Zerbato, Nicole A. (DOC); 'Adams, Karen P. (DOC); Brandis, Althea L. (DOC); Davis, Kimberly M. (DOC); 

Johnson, Kathleen T. (DOC); Johnson, Sarah R. (DOC); Kendo, Richard A. (DOC); McKenna-Smith, Katherine E. (DOC); McKenzie, 

Jane M. (DOC); Miller, Tina K. (DOC); Rimple, Larry R. (DOC); Rosales, Ricardo (DOC); Smith, Shannon M. (DOC); Young, Dianne 

M. (DOC) . 

Subject: 

RE: Heads up! 

· Just an FYI--I recently spoke with three different pharmacies regarding the '''medical marijuana" issue. All three informed 

me that it is illegal to dispense marijuana in any form in Washington State, and that no legally licensed pharmacy or 

pharmacist would do this. The closest product that they carry, whi.ch is prescribed to some cancer patients is called 

Marninol, and it's packaged in capsule form. . 

So, if an offender says that they got their mariju~na from a licensed pharmacy, they are being deceptive. 

-----Original Message---- . 

From: Julian, Patricia A. (DOC) On Behalf Of Lindell, Katrina R. (DOC) 

Sent: 

Tuesday, November 06, 2007 1Q:46 AM 

To: Zerbato, Nicole A. (DOC); Adams, Karen P. (DOC); BrandiS, Althea L. (DOC); Davis, Kimberly M. (DOC); Freeman, Gregg P. 

(DOC); Johnson, Kathleen T. (DOC); Johnson, sarah R. (DOC); Kend9, Richard A. (DOC); McKenna-Smith, Katherine E. (DOC); 

McKenzie, Jane M. (DOC); Miller, Tina K. (DOC); Rimple, Larry R. (DOC); Rosales, Ricardo (DOC); Smith, Shannon M. (DOC); 

Young, Dianne M. (DOC) 

Subject: 

FW: Heads upl 

Importance: High 

Please see the email below from Heidi Bale. 

Pat Julian, Administrative Assistant 3 


8629 Evergreen Way, Suite 100 

Everett WA 98208-2620 

1 

PDU-6655-3 000112

425-513-5238 

FAX 425-356-2899 

----Original Message----- 

From: 

. Raymond, Brooks M. (DOC) 

Sent: 


To: 

Lindell, Katrina R. (DOC); Vernell, Eleanor D. (DOC) 

Subject: FW: Heads up! . 

Just fyi for your staff 

-----Original Message----- 

From: 

Bale, Heidi H. (DOC) 

Sent: 


To: 

Marrs, Steve D. (DOC); Raymond, BrookS M. (DOC) 

Subject: Heads up! . 

Apparently there is a clinic iii Bellevue handing out "prescriptions" for medical marijuana. An offender called health 

services this. morning, saying he had filled his pr~scription a.nd wanted to know DOC stance ... : 

Dr: Thomas Orvald, 

Website has all the information, with Bellevue clinic address. wwW.thcfoundation.com/clinicsf 

Patient self referred himself. 

Heidi Bale, RN

Distefano, Moriica J. (DOC) 

From: 

. Sent: 

To: 

Cc: 

Subject: 

Freeman, Gregg P. (DOC) 

Wednesday, December 31, 20082:43 PM 

DOC DL NW 227 OAK HARBOR 

Lindell, Katrina R. .(DOC) 

Oak Harbor Case Staffings 12/30/08 

I 

• ! 

I 

1" 

I 

! 

i 

I 

I 

i 

I 

Case staffings Were held in the Oak Harbor Office with Rob Diekman, Lisa Lee, and me present. The following 

topics/cases were discussed: 

. General: 

• still having problems with Compass Health in terms of communication and timely response to referrals. Corky 

Hundahl, of Phoenix Recovery, is interested in possibly providing on-site CD services for the Oak Harbor Office, and 

I'll invite her to come over and meet with.staff, maybe next week, to discuss things. Once we know what services 

Phoenix can provide, I'll arrange to meet with G-Ray at Compass to discuss concerns over their contract performanc~. 

• We reviewed the recent memo from Karen Daniel's that extends the 12/31/08 due date for classification conversion 

indefinitely, and indicates that the CCR conversion team may be made permanent and complete all static risk . 

assessments for the field. 

•. Zac will be starting full time in Oak Harb9r on 1/12/09. He will continue to assist the Mount Vernon Office with intakes 

until the OMMU cases are transferred to us from Seattle. 

Case Staffings: 

, 

Rob: 

Louie Scarpino: Still in custody on-'::harges that precede his current ~upervisionwith us. Rob will address 

Louie's positive UA's with a sti~ement given current confinement and the charges he is facing . 

. Richard Polaski: Due to release from violator confinement this week. 'WiII be returning to his former address. 

Unfortunately, the IPI request to Illinois is not an option at this time. 

Lisa: 

Colin Burner: Released from prison yesterday and is an imminent threat case who's victim lives locally. Colin reported 

that his victim called his parent's home yesterday leaving a threatening message. Lisa called the victim and she 

admitted to having left the message. Lisa asked her to have no further contact with Colin or his family, and she has 

imposed a no-contact order on Colin that prevents him from having contact with the victim without CCO consent. Lisa 

will work with the parties regarding visitation issues, which is allowed by the J&S. Lisa will set clear guidelines for the 

offender as he does have violence potential and significant risk factors. 

_ 

This is a new case who .has been prescribed medicinal use. of marijuana. P is cur~ently in custody. Lisa will 

get a ROI to allow her to obtain medical verification from the provider per the recent policy. 

Er,ic Barbarisi: His hearing has been continued to the middle of January. Eric called Lisa and indicated that his wife may 

have an apartment manager job in Whatcom County, and he wondered whether he would again be required to 

disclose his criminal conviction to the employer if he lived with her. He was' told that he would be required to disclose; 

at which point he indicated that he may remain in Skagit County and his wife would move to Bellingham. He has his 

rent paid at a Mount Vernon hotel through January 1st. 

Shaun Jackson: Now at ABHS. 

Sharon Willig: New case who is living with Stuart Vates, a known drug user. The location presents Officer safety 

concerns, and so Lisa will take LE with her when doing home visits. She and Helen went to the house last week and 

there are three surveillance cameras around the home, and a large pitbull. The house is in a rural area. We'll need to 

be very cautious when making home contacts. 

1 . 

PDU-6655-3000114

Think Green~-Do not print a copy of this email unless absolutely necessary. 

Gregg Freeman, CCS 

Mount Vernon/Oak Harbor DOC Office 

707 So. 2nd Street 

Mount Vernon, WA 98273 

Office: (360) 428-1361 

Cell: (360) 661-5690 

.. 

2 

PDU-6655-3 000115

j 

I 


From: 

Sent: 

To: 

Subject: 


Wednesday, April 01, 2009 12:21 PM 

Berthon, Ralph M. (DOC); Lindell, Katrina R. (DOC) 


Thanks, Ralph. I think you make some very good points. Katrina- FYI for our discussion next week. 

Stej'aniJWeusvorn 

:J'ie[a .Jtaministrator 


Office: 360-571-4333 

Ce[[: 360-772'3793 

From: 

Sent: 

To: 

Subject: 

BeMon, Ralph M. (DOC) 


. Witten, Dell-Autumn W. (DOC); Meusborn-Marsh, Stefani L. (DOC) 


~~,. . 

I really cannot tell you how many times I have seen this policy or who all have sent it to me for review in the past year. I 

am excited (I hope it doesn't show!) to see we Ire close to putting it to bed. I have read this version and made one 

minor change that I can liye with or without. It has to do with the ten day contact rule. I added a couple of words in 

regard to intakes as it is not captured in the intake policy 310.100. 

In regard to Autumn's remarks below; I can see adding the KIOSK language because it directly applies to supervision 

on a global scale. . 

As for the violations language, we need to take it out and do an Admin Bulleting (AB) to the violations policy. In this 

case the violation data can be captured in an AB, the new 380.200 can go out, when the violation policy gets are-write 

we add the AB data and we are all happy. Well almost all of us. And of course the same logic applies to the 

Community Supervision of high Risk offender's piece; take it out, put it into and AB and be done with it. 

The medical marijuana piece; that too belongs in a violation policy as it related directly to the process for estaplishing 

credibility to violate someone. In that there is al) AB already out on marijuana, we could amend that bulletin and re 

issue it and tie it to the violation policy. . 


I do not want to ruffle feathers, and it may be showing a·bit but one area that I feel strongly is these are easy fixes to a 

difficult process of re-writing pOlicies. I will admit that having AS's come out all thf3 time seems to. makes us look a little 

disjointed and lacking in direction, but it is what it is. From one persons perspective it is not a good enough reason to 

have policies constantly changing or in "draft" status for months/years while stuff is pending a change in another policy; 

or to issue a policy knowing we will have to re write it again and then just riot getting to it for a year or more. If we are 

planning any p.olicy change then let's shoot for making it a singular one time fix to a policy instead of having to re-write 

one policy every time we re-write another policy. 

Ralph 

i , . 

From: Witten, Dell-Autumn W. eDOC) 


To: Berthon, Ralph M. eDOC) 


« File: 380200.doc» 

Here you go. Let me know if you have questions. Thank you! 

1 

PDU-6655-3000116

From: 

Sent: 

To: 

Subject: 

Meusborn-Marsh, Stefani L (DOC) 


Berthon, Ralph M. (DOC); Witten, Dell-Autumn W. (DOC) 


Ralph- PI~ase take a look and give me some feedback. Thanks. 

Stefani MeusGor,t . 

:fie{a 2laministrator 


Office: 360-571-4333 

Ce{t: 360-772-3793 

From: 


Sent: 


To: Meusborn-Marsh, Stefani L (DOC) . 

Subject: 



Thank you! 

From: 


Sent: 


To: 

,Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC) 

Subject: FW: 380 200 COmmunity Supervision of Offenders 

. . 

Katrina- Sin,ce you are the official policy owner on this one, let's take a look at this toge.ther .. Thanks. 

Stefani MeusGorn 

:fie W.Jtarninis trcitor 


Office: 360-571-4333 

Ce{{: 360-772-3793 

.From: 

. Sent: 

To: 

Subject: 





Hi Stefani: . 

More questions on this draft. Please let me know where this information has been moved to or if it was removed 

as redundant: . 

Violations --I have a note that this language was going to be moved to DOC 320.145 Violator Confinement in 

Department Facilities, but it hasn't been yet. It should not be removed until it gets moved to 320.145. 

Community Supervision of High Risk Offenders -- Since 380.100 was in Annual Review, this policy needs to, 

be processed now. If this was removed on account of Risk Management Teams and they have not been 

disbanded yet, the langut;lge should stay in. . . 

I also have notes that language from DOC 380.250 GENIE/KIOSK Use in Offender Su'pervision should be added 

to this policy so that one can be rescinded. I suggest adding it under Offender/Collateral Contacts. Let me know if 

you concur.. 

2 

PDU-6655-3 000117

E.... 

KIOSK reporting may be used in the following circumstances: 

1. To supplement, but not replace, in-person reporting for High and 

rytoderate Risk offenders and Low Risk offenders required to register. 

2. Low Risk offenders not required to register will report to KIOSK and be 

primarily ·managed using GENIE/KIOSK resources. 

3. DOSA offenders may report to KIOSK, but will also have weekly in-person 

contact until admitted to chemical dependency treatment. . 

4. For enhanced reporting requirem·ents for homeless offenders. 

5. GENIE/KIOSK may be used as a supervision enhancement to monitor 

legal financial payments and to assist with the scheduling and notification 

of urinalysis testir:g requirements. 


Thank you! 

From: 

Sent: 

To: 

Subject: 


Friday, March 27,2009 3:05 PM 

Meusbom-Marsh, Stefani L. (DOC)· 


Hi Stefani: 

Quick Question - Regarding offender supervision, has the content on inactive Administrative Phases A and 8 been 

moved to the ceo manual, O~· has it gone away entirely 

Please let me know,. 

Thank you! 

From: 

McKenzie, Jane M. (DOC) On Behalf Of Lindell, Katrina R. (DOC) 

Sent: Friday, March 13, 2009 3:23 PM .. 

To: 

Witten, Dell-Autumn W. (DOC); Meusbom-Marsh, Stefani L. (DOC) 

Cc: Undell, Katrina R. (DOC) . 

Subject: 


Autum n, Katrina has reviewed and approved the below policy that has incorporated 380.100. There are some 

formatting issues but am not sure if you want me to do that or not. P!ease let me know. Thanks, Jane 

From: 

Sent: 

To: 

Cc: . 

Subject: 

Miller, Merlin K. 'Un' (~OC) 

Tuesday, February 17, 2009 8:56 AM 

Undell, Katrina R. (DOC) . 



Katrina/Stef, a couple·more comments made in red in the attached. 


.From: Meusborn-Marsh, Stefani L. (DOC) 


To: Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC)i Miller, Merlin K. 'Lin' (DOC); McKenzie, Jane M. 


Subject: 380 200 Community Supervision of Offenders . 

3 

PDU-6655-3 000118

0 

« File: 380 200 Community Supervision of Offenders. doc » Katrina - Here is the policy after having· 

gone through my simplification and run past the union, the policy owner, Lin and the RA's for comment. I have 

also. combined this with 380.100 Offender Supervision Status. So that policy will no longer exist. There was 

discussion about the Medicinal Use of Marijuana being included in this policy -I really·do not think it belongs here, 

but am not sure just where is should gothis is the policy the AS put it in so I left it here. In the future w~en the 

annual review is done, maybe there should be some consideration of placing it in the 320.155 Violation PoliCY 

Also the other area that causes eyebrows to lift is the Duty Officer Coverage sectionit really does not belong in 

this policy but where does it belong: Lin suggested 370.100- unfortunately, that policy is just being developed. 

Autumn- This is on to you - I am keeping all of my notes. for reference on this one. Please also see the above 

as you may want to switch some things around. . 

Lin- Please take one last look to make sure this all inakes sense, please .............it is all running together on me 

now. . 

.' 

i 

1 

I '0 

4 

PDU-6655-3 000119


~age 1 of4 

Distefano,' Monica J. (DOC) 


Sent: Wednesday, April 01,2009.8:43 AM 



How about Monday" I have nothing scheduled for the day so far. 

Stefani Meusvorn 

jFie{c{Jtc(r,nu1litrator 

. sVV 'Region Se,ction 3 

Office: 360-571-4333 

Ce{{; 360-772-3793 

----._,_._-- 

From: Lindell, Katrina R. (DOC) 

sent: Tuesday, March 31, 2009 3:38 PM 



Deposition all day Friday .. Next week 

From: Meusborn-Marsh, Stefani L (DOC) 

sent: Tuesday, March 31, 2009 10:53 AM 


Subject: Re: 380 200 Community Supervision of Offenders 

Negotiaions all d~y- how about Frida.Y 

~rom: Lindell, Katrina R. (DOC) 


.Sent:,Tue Mar 3110:39:232009 

Subject: RE: 380 200 Community Supervision. of Offenders 

I will be up in Bellingham. What does Thursday loo'k like for you 


Sent: Monday, March 30, 2009 6:52 PM , 

To: Lindell, Katrina R. (DOC) . 

Subject: Re: 380 200 Community Supervision of Offenders 

I will be back in the office Wed~ you available' 

From: Lindell, Katrina R. (DOC) 

5/13/2009' 

PDU-6655-3000120

, 

1 

f 

RE: 380200 Community Supervision of Offenders 

To: Meusborn-Marsh, Stefani L. (DOC)i Witten, Dell-Autumn W. (DOC) 

Sent: Mon Mar 3013:29:492009 


Page2of4 

Sounds good. Let me know what will work best for you 



To: Undell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC) 


Katrina- Since you are the official policy owner on this one, let's take a look at this 

together. Thanks. 

Stefani JvleusVont 

J'ie[tf .Jtc[ministrator 

SW 'Region Section 3 

Office: 36.0-571-4333 

Ce[[: 360-772-3793 



To: 'Meusborn-Marsh, Stefani L (DOC) 

Subject: FW: 380200 Community Supervision of Offenders 

Hi Stefani: 

More questions on this draft. Please let me know where this information has been 

moved to or if it was removed as redundant: 

. . 

Violations -- I have a note that this language was going to be moved to DOC 

320.145 Violator Confinement in Department·Facilities, but it hasn't been yet. It 

should-not be removed until'it gets moved to 320 .. 145 .. 

Community Supervision of High Risk Offenders - Since 380.100 was in Annual 

Review, this policy needs to be processed now. If this was removed on account 

of Risk Management Teams and they have not been disbanded yet, the' 

. language should stay in. 

I also have notes that language from DOC 380.250 GENIE/KIOSK Use in Offender 

Supervision should be added to this policy so that one can be rescinded; I suggest 

adding it under Offender/Collateral Contacts. Let me know if you concur. 



Moderate Risk offenders and Low Risk offenders required to register. 

~ Low Risk offenders not required to register will report to KIOSK and be 

primarily managed using GENIE/KIOSK resources. 

5/13/2009 

PDU-6655-3000121


Page 3 of4 

. 3. DOSA offenders may report to KIOSK, but will also have weekly inperson 

contact until admitted to chemical dependency treatment. 

4. .For enhanced reporting requirements for home'less offenders. 

5. GENIE/KI.OSK may be used as a supervision enhancement to monitor 

legal financial payments and to assist with the scheduling and notification of 

urinalysis testing requirements. 


Thank you! 



To: Meusbom-Marsh, Stefani L (DOC) 

Subject: FW: 380 200 Community Supervision of .offenders 

Hi Stefani: 

Quick Question - Regarding offender supervision, has the content on inactive 

Administrative Phases A and B been moved to the ceo manual, or has it gone away 

entirely . 


Thank you! 

From: McKenzie, Jane M. (DOC) On Behalf Of Lindell .. Katrina R. (DOC) 

Sent: Fri.day, March 13, 2009 3:23 PM 


. Cc: Lindell, Katrina R. (DOC) , 

Subject: FW:.380 200 Community Supervision of Offenders 

Autumn, Katrina has reviewed and approved the below policy that has incorporated 

380.100. There are some formatting issues but am not sure if you want me to do that 

or not. Please let me know. Thanks, Jane 


Sent: Tuesday, February 17, 2009 8:56 AM 


Cc: . Meusborn-Marsh, Stefani L. (DOC) 


Katrina/Stef, a couple more comments made in red in the attached. 

(Stef, I know how you feel about the policy, now just virant to it DONE.) 


sent: Friday, February 13, 2009 2:22 PM . 

. To: Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC); Miller, Merlin K .. 

'Lin' (DOC); McKenzie, Jane M. (DOC) 

5/13/2009 

PDU-6655-3 000122


Page 4 of4 

Subject: 380 200 Community Supervision of Offenders 

«File: 380 200 Community Supervision of Offenders. doc"» Katrina -.Here 

is the policy after having gone through my simplification and run past the union, the 

policy owner, Lin and the RA's for com·ment. I have also combined this with 380.100 

Offender Supervision Status. So that policy will no longer exist. There was 

discussion about tlie Medicinal Use of Marijuana being included in this policy - I really 

do not think it belongs here, but am not sure Just where is should. gothis is the policy 

the AB put it in so I left it here. In the future when the annual review is done, maybe 

there should be some consideration of placing it in the 320.155 Violation Policy 

Also the other area that causes eyebrows to lift is the Duty Officer Coverage sectionit 

really does not belong in this policy but where does it belong. Lin suggested 

370.1.00- unfortunately, that policy is just being developed. 

Autumn- This is on to you - I am keeping all of my notes for reference on this one. 

Please also see the above as you may want to switch some things around. 

Lin- Please take one last look to make sure this all makes sense, please: ............ it is" 

all running together on me now. . 

5/13/2009· 

PDU-6655-3 000123

'---.- .... _-- _.,,-.... 


From: 

Sent: 

To: 

Subject: 

Lindell, Katrina R. (DOC) 

Thursday, April 02, 2009 2:20 PM 

Meusborn-Marsh, Stefani L. (DOC); Berthon, Ralph M. (DOC) 


Very good. Thanks to you both. 

Katrina 

From: 

Sent: 

To: 

Subject: 

Meusbom-Marsh, Stefani L. (DOC) 

Wednesday; April 01, 2009 12:21 PM 

Berthon, Ralph M. (DOC); Lindell, Katrina R. (DOC) 


Thanks, Ralph. I think you make some very good points. Katrina- FYI for our discussion next week . 

. Stefani Jvlew60rn 

:fie [a :Aaministrator 

SW 'Region Section 3 

Office: 360-571-4333 

Cere: 360-772-3793 

From: 

Sent: 

To: 

Subject: 

Berthon, Ralph M. (DOC) 


Witten, Dell-Autumn W. (DOC); Meusbom-Marsh, Stefani L. (DOC) 

FW; 380 200 Community ,supervision of Offenders 

Folks, . . 

I really cannot tell you how many times I have seen this policy or who all h'ave sent it to me,for review in the past 

. year. I am excited (I hope it doesn't show!) to see we are close to putting it to bed. I have read this version and 

made one minor change that I can live with or without. It has to do with the ten day contact rule. I added a couple 

of words in regard to intakes as it is not" captured in the intake policy 310.100. 

In regard to Autumn's remarks below, I can see adding the KIOSK language because it directly applies to 

supervision on a global scale~ . 

As for the violations language, we need to take it out and do an Admin Bulleting (AB) to the violatioris policy. In this 

case the violation data can be captured in an AB, the new 380.200 can go out, when the violation policy gets a rewrite 

we add the AB data and we are all happy. Well almost all of us. And of course the same logic applies to the 

Community Supervision of high Risk offender's piece; take it out, put it into and AB and be done with !t. 


establishing credibility to violate someone. In that there is an AB already out on marijuana, we could amend that 

bulletin and re issue it and tie it to the violation policy. 

Two more cents worth: . 

I do not want to ruffle feathers, and it may be showing a bit but one area that I feel ~tr6ngly is these are easy fixes 

to a difficult process of re-writing pOlicies. I will admit that having AB's come out all the time seems to makes us 

look a little disjointed and lacking in direction, but it is what it is. From one persons perspective it is not a good 

enough reason to have poliCies constantly changing or in "draft" status for months/years while stuff is pending a 

change in another policy; or to issue a policy knowing we will have to re write it again and then just not getting to it 

for a year or more. If we are planning any policy change then let's shoot for making it a singular one time fix to a 

policy instead of having to re-write one policy every time we re-write another policy .. 

Ralph 


PDU-6655-3 000124

sent: Wednesday, April 01, 2009 9:21 AM 

To: Berthon, Ralph M. CDOC) 


«File: 380200.doc» 

Here you go. Let me know if you have questions. Thank you! 

From: 


Sent: , Monday, March 30, 2009 10:43 AM " 

To: 

Berthon, Ralph M. (~OC); Witten, Dell-Autumn W. (~OC) 

Subject: 


Ralph- Please tak~ a look and give me some feedback. Thanks. 

, Stefani :MeusEorn 

:fie {a :A.aministrator 

, SW 'Region Section 3 

Office: 360-571-4333 

Ce{{: 360-772-3793 

From: 

Sent: 

, To: 

Subject: 

Witten, Pell-Autumn W. (DOC) 


Meusbom-Marsh, Stefani. L. (ElOC) 



Thank you! 

From: 

Sent: 

To: 

Subject: 

Meusbom-Mars~, Stefani L. (~OC) 


~indell, Katrina R. (~OC); Witten, Dell-Autumn W. (DOC) 


Katrina- Since you are the officiai policy owner on this one, let's take a look at this together. Thanks. 

Stefani :MeusEorn 

:fieU{:A.aministrator 


Office: 360-571-4333 

Ce{{: 360-772-3793 

From: 

Sent: 

To: 

Subject: 

Witten, Deli-Autumn W. (~OC) 


M,eusbom-Marsh, Stefani L. (DOC) 


, Hi Stefani: 

More questions on this draft. Please let me know where this information has been moved to or if it was 

removed as redundant: 

Violatfons -- I have a note that this language was going to be moved to DOC 320.145 Violator 

Confinement in Department Facilities, but it hasn't been yet. It should not be removed until it gets moved 

to 320.145.' 

' 

Community Supervision of High Risk Offenders - Since 380.100 was in Annual Review, this policy needs 

.2 

PDU-6655-3 000125

to be processed now. If this was removed on account of Risk Management Teams and they have not 

been disbanded yet, the language should stay in. 

I also have notes that language from DOC 380.250 GENIE/KIOSK Use in Offender Supervision should be 

added to this policy so that one can be rescinded. I suggest adding it under Offender/Collateral Contacts. Let 

me know if you concur. . 



Moderate Risk offenders and Low Risk offenders required to.register. 

2. Low Risk offenders not required to register will report to KIOSK and be .. 

primarily managed using GENIE/KiOSK resources. . 

3. . DOSA offenders may report to KIOSK, but wilL also have weekly inperson 

contact until admitted to chemical dependency treatment. 

4. For enhanced reporting requirements for homeless offenders. 

5. GENIE/KIOSK may be used as a supervision enhancement to monitor 

legal financial payments and to assist with the scheduling and 

notification of urinalysis testing requirements. 


Thank you! 

From: 

Sent: 

To: 

Subject: 

. Witten, Dell-Autumn W. (DOC) 

Friday, March 27, 2009 3.:05 PM 


FW: 380 200 CommunitY Supervision 9f Offenders 

Hi Stefani: 

Quick Question - Regarding offender supervision, has the content on inactive Administrative Phases A and B 

been moved to the CCO lT!anual, or has it gone away entirely 


Thank you! 

From: 

Sent: 

To: 

Cc: 

Subject: 

McKenzie, Jane M. (DOC) On Behalf Of Lindell, Katrina R. (DOC) 

Friday, March 13, 20093:23 PM 

Witten, Dell-Autumn w. (DOC); Meusborn-Marsh, Stefani L. (DOC) 



Autumn, Katrina has reviewed and approved the below policy that has incorporated 380.100. There are some 

. formatting issues but am not sure if you want me to do that or not. Please let me know. Tharik~, Jane 

From: . 

Sent: 

To: 

Cc: 

Subject: 

Miller, Merlin K. 'Lin' (DOC) 

Tuesday, February 17, 2009 8:56 AM . 


Meusbom-Marsh, Stefani L. (DOC) 



:. 

I 

(Stef, I know how you feel about the policy, f')ow just want to it DONE.) 

3 

PDU-6655-3 000126

From: Meusborn-Marsh, Stefani L. (~OC) 


'. 

To: Lindell, Katrina R. (~OC); Witten, Oell~Autumn W. (~OC); Miller, Merlin K. 'Lin' (~OC); McKenzie, Jane M. 

(~OC) 

_ Subject: 380 200 Community Supervision of Offenders 

«File: 380200 Community Supervision of Offenders. doc » Katrina - Here is the policy after 

having gone through my simplification and run past the union, the policy owner, Lin and the RA's for comment. 

I have also combined this with 380.100 Offender Supervision Status. So that policy will no longer exist. _ 

There was discussion about the Medicinal- Use of Marijuana being included in this policy - I really-do not think it 

belongs here, but am not sure just where is should gothis is the policy the AB put it in so I left it here. In the 

future when the annual review is done, maybe there should be some consideration of placing it in the 320.155 

Violation Policy Also the other area thCt causes eyebrows to lift is the Duty Officer Coverage sectionit 

really does not belong in this policy but where does it belong. Lin suggested 370.100- unfortunately, that 

policy i~ just being developed. - 

Autumn- This is on to you - I ani keeping all of my notes for reference on this one. Please also see the 

above as you may want-to switch some things around. _ 

Lin- Please take one last look to make sure·this all makes sense', please ..............it is all running together on 

me now. 

i 

I 

4 

PDU-6655-3000127


From: 

Sent: 

To: 

Subject: . 

Lindell, Katrina R: (DOC) 

Monday, March 30; 2009 1.:30 PM 

Meusborn-Marsh, Stefani L. (DOC); Witten, Dell-Autumn W. (DOC) 


Sounds good. Let me know what will work best for you 

From: 

Sent: 

To: 

Subject: 

Meusborn-Marsh, Stefani L. (DOC) . 

Monday, March 30, 2009 10:40 AM . 

Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC) 


Katrina- Since you are the official policy owner on this one, let's take a .Iook at this together. Thanks. 

, 

! 

I' 

St~ani~eUShorn 

:f'ie{cC .Jtc{ministratoy 

. SVV 'Region Section 3 

Office: 360-571-4333' 

Ce{{: 360-772-3793 

From: 

Sent: 

To: 

Subject: 





Hi Stefani: 

More questions on this draft. Please let me know where this information has been moved t6 or·if it was removed as 

redundant: 

Violations -'- I have a note that this language was going to be moved to DOC 320.145 Violator Confinement in 

Department Facilities, but it hasn't been yet. It should not be removed until it gets moved to 320.145. 

Community SuperviSion of High Risk Offenders -- Since 380.100 was in Annual Review, this policy needs to be 

processed now. If this was removed on account of Risk Management Teams and they have not been disbanded. 

yet, the language should stay in. . 

I also have notes that,language from DOC 380.250 GENIE/KIOSK Use in Offender Supervision should be added to 

this policy so that one can be rescinded. I suggest adding it under Offender/Collateral C~>ntacts. Let me know if you 

concur .. 

E~ KIOSK reporting may be used in the following circumstances: 

1. To supplement, but not replace, in-person reporting for High and Moderate 

Risk offenders and Low Risk offenders required to register. . 

2. Low Risk offenders not required to register will report to KIOSK and be 

primarily managed usingGENIE/KIOSK resources. 

3. . DOSA offenders may report to KIOSK, but will also ~ave weekly in-person 

contact until admitted to chemical dependency treat~ent. 

4. For enhanced reporting requirements for homeless offenders. 

1 

PDU-6655-3000128

5. GENIE/KIOSK may be used as a supervision enhancement to monitor legal 

financial payments and to C\ssist with the scheduling and notification of 

urinalysis testing requirements. 


Thank you! 

From: 

Sent: 

To: 

Subject: 


Friday, March 2.7, 2.009 3:05 PM 

Meusbom-Marsh, Stefani L (DOC) 

FW: 380 2.00 Community Supervision of Offenders 

Hi Stefani: 

Quick Question - Regarding offerider supervision, has the content on inactive Administrative Phases A and B been 

moved to the CCO ·manual, or has it gone away entirely 


Thank you! 

From: 

Sent: 

To: 

Cc: 

Subject: . 

McKenzie, Jane M. (DOC) On Behalf Of Lindell,.Katrina R. (DOC) 

Friday, March 13, 2.0093:2.3 PM 

Witten, Dell-Autumn W. (DOC); Meusborn-Marsh, Stefani L (DOC) 



Autumn, Katrina has reviewed and approved the b.elow policy that has incorporated 38.0.100. There are some 

formatting issues but am not sure if you want me to do that or not. Please let me know. Thanks, Jane 

From: 

Sent: 

To: 

Cc: 

Subject: 

Miller, Merlin K. 'Lin' (DOC) 

Tuesday, February 17, 2009 8:56 AM 






From: Meusbotn-Marsh, Stefani L. (DOC) 

Sent: Friday, February 13, 2009 2:22 PM " 

To: Lindell, Katrina R. (DOC)i Witten, Dell-Autumn W. (DOC)i Miller, Merlin K. 'Lin' (DOC)i McKenzie, Jane M; (DOC) 

SUbject: 380 200 Community Supervision of Offenders 

Katrina - Here is the policy after having 

gone through my simplification and run past the union, the policy owner, Lin and the RA's for comment. I have also 

combined this with 380.100 Offender Supervisibn Status. So that policy will no longer exist. There was discussion 

about the Medicinal Use of Marijuana being included in this policy - I really do not think it belongs here, but am not 

sure just where is should gothis is the policy the AB put it in so I left it here. In the future when the annual review. is 

done, maybe there should be some consideration of placing it in the 320.155 Violation Policy Also the other area 

that causes eyebrows to lift is th~ Duty Officer Coverage sectionit really does not belong in this p.olicy but'where 

does it belong. Lin suggested 370.100- unfortunately, that policy is just being developed. 

«File: 380200 Community Supervision of Offenders. doc » 

Autumn- This is on to you - I.am keeping all of my notes for reference on this one. Please also see the above as 

you may want to switch some things around. 

Lin~ Please take" one last look to make sure this all makes sense, please ...........;.it is all running together on me 

now. 

2. 

PDU-6655-3 000129

FW: 380200 Community Supervision ofOfferiders 

Page 1 ofS 


From: Witten, Dell-Autumn W. {DOC} 



Cc: Meusborn-Marsh, Stefani L. {DOC}; McKenzie, Jane M. {DOC} 


The content of DOC 380.250 GENIE/KIOSK Use in Offender Supervision has been divvied out into several 

policies (i.e., 310.100, 380.600, 380.650, 460.130),.though the bulk is being added here. It will not be rescinded 

until the last of the policies -- DOC' 460.130 probably, at the rate it's moving - gets published. 

Thankyoul 

, 

i 

From: !.:indell, Katrina R. (DOC) 


To: Witten, Dell-Autumn W. (DOC) 

Cc: Meusborn-Marsh, Stefani L. (DOC); McKenzie, Jane M. (DOC) 


Autumn, 

Where. did the other information go regarding Genie/Kiosk use in offender supervision The suggestion to 

add the Kiosk Reporting listed below works for this poli~y. However, we need to be mindful not to l.ose 

the information that was Included in doc 380.250 Genie/Kiosk. 

Katrina 


Sent: Thursday, April 02, 200911:17 AM 

To: Lindell, Katrina R. (DOC) . . 


From: Witten, D~II-Autumn W. (DOC) 


Sent: Thu Apr 02 11:00:50 2009 . 


Hi Stefani: 

I have made the change RaJ ph suggests and added the KIOSK info to facilitate rescinding 380.250, and 

will work with Lin on placing the violator information in the 320.145 AS he's drafting. Ralph would like to 

move medicinal marijuana too, and I'll check on that with Lin. . 

So now I just need to resolve the Community Supervision of High Risk Offenders section. Please advise. . 

Thank you! 

. 5/1:3/2009 

PDU-6655-3000130


Page 2 of5 

From: 

Berthon, Ralph M. (DOC) 



Subject: 

FVV: 380 200 Community Supervision of Offenders 

Folks, 

I really cannot tell you how many times I have seen this policy or who all have sent it to me for review in the. 

past year. I am excited (I hope it doesn't show!) to see we are close to putting it to bed. I have read this 

version and made one minor change that I can live with or without. ,It has to do with the ten day contact 

rule. I added a couple of words in regard to intakes as it is not captured in the intake policy 310.100. 

In regard to Autumn's remarks below, I can see adding the KIO$K language because it directly applies to 

supervision on a global 'scale. 

As for the violations language, we need to take it out and do an Admin Sulleting (AS) to the violations 

policy. In this case the violation data can be captured in an AS, the new 380.200 can go out, when the 

Violation policy gets a re-write we add the AS data and we are 'all happy. Well almost all of us. And of 

course the same logic applies to the Community Supervision of high Risk offender's piece; take it out, put it 

into and AB and be done with it. -. 


establishing credibility to violate someone. In that there is an AS already out on marijuana, we could 

amend that bulletin and re issue it and tie it to the violation policy. 


I do not want to ruffle feathers, and it. may be showing a bit but one area, that ,I feel strongly is ,these are 

easy fixes to a difficult process of re-writing poliCies. I will admit that having AS's come out all the time 

seems to makes us look a little disjointed and lacking in direction; but it is what it is. From oO~ persons 

perspective it is not a good enough reason to have policies constantly changing or in "draft" status for 

months/years while stuff is pending a change in another policy; or to issue a policy knowing we will have to 

re write it again and then just not getting to it for a year or more. If we are planning any policy change then 

let's shoot for making it a singular one time fix to a policy instead of having to re-write one policy every time 

we re-write another policy. , ' . 

Ralph. 

From: Witten, Dell-Autumn W. (DOt) 

Sent: yvednesday, April 01, 2009 9:21 AM 

To: Serthon, Ralph M. (DOC) 

Subject: FW: 380 200. Community Supervision of O~enders 

«380200.doc» 

Here you gO'. Let me know if you have questions. Thank you! 



To: Berthon, Ralph M. (DOC); Witten, Dell-Autumn W, (DOC) 

Subject: FVV: 380 200 Community Supervision of Offenders 

Ralph- Please take a look and give me some feedback. Thanks. 

Stefani .7vleushoY1t 

5/13/2009 

PDU-6655-3000131

FW: 380200 Community Sup_ervision of Offenders 

Page 3 of5 

:fie W.Jtaminis trator 

sVV 'Region Section 3 

,Office: 360-571-4333 

CeCe: 360-772-3793 


Sent: Monday, March 30, 2009 10:.'41 AM 

To: Meusborn-Marsh, Stefani L. (bOC) 


R~lph Berthon owns' 380.200. Please include, him as well. 

Thank you! 

From: Meusborn-Marsh! Stefani L. (DOC) 

Sent: Monday, March 30, io09 10:40 AM . 

To: Lindell, Katrina R. (DOC); Witten, Dell-Autu~n W. (DOC) 


Katrina- Since you are the official policy owner on this one, let's take a look at this together. 

Thanks. 

Stefani JvLeusDorn 

:fieCa .Jtd7niniStrator 

SVV 'R:egion SeCtion 3,' 

Office: 360-571-4333, 

CeCe: 360"772-3793 


Senti Monday, March 30, 2009 8:53 AM ' 

To: Meusborn-Mqrsh, Stefani L. (DOC) 

Subject: fIN: 380 200 Community Supervision of Offenders 

Hi Stefani: ' 

, MorC questions on this draft. Please let me know where this information has ,been moved to or if it 

was removed as redundant: 

Violations - I have a note that this language was going to be moved to DOC 320.145 Violator 

Confinement in Department Facilities, but it hasn't been yet. It should not be removed until 'it 

gets moved to 320.145. 

' 

Community Supervision of High Risk Offenders - Since 380.100 was in Annual Review, thi;s 

policy needs to be processed now. If this was removed on account of Risk Management 

Teams and they have not been disbanded yet, the language should 'stay in. 

5/13/2009 

PDU-6655-3 000132

.- ·_. __ ._--_. __ .-.- -------~------------ 


Page 4 of5 

I also have notes that language from DOC 380.250 GE.NIE/KIOSK Use in Offender Supervision 

should be added to this policy so that one can be rescinded. I suggest adding it under 

Offender/Collateral Contacts_ Let me know if you concur. 

E. KIOSK reporting may be used in the following circumstances: . 

1. To supplement, but not repla~e, in-person reporting for High and Moderate Risk 

offenders and Low Risk offenders required to register. 

~ Low Risk offenders not required to register will report to KIOSK and be primarily 

managed using GENIE/KIOSK resources_ 

3. DOSA offenders may report to KIOSK, but will also have weekly in-person contact 

until admitted to chemical dependency treatment. . 

4. For enhanced reporting requirements for homeless offenders_ 

5_ GENIE/KIOSK may be used as a supervision Emhancement to monitor legal 

financial payments and to assist with the scheduling and notification of urinalysis testing 

requirements. 


Th~nk you! 

From: Witten, Dell-Autumn W. (~OC) 

sent: Friday, March 27, 2009 3:05 PM 

To: Meusborn-Marsh, Stefani L. (~OC) 

Subject: . FW: 380 200 Community Supervision of Offenders 

Hi Stefani: 

Quick Question - Regarding offender supervision, has. the content on inactive Administrative Phases 

A and B been moved to the ceo manual, or has.it gone away entirely 

. . 

Please let me know,· . 

Thank you! 

From: McKenzie, Jane M. (~OC) On Behalf Of Lindell, Katrina R. (~OC) 


To: Witten, Dell-Autumn W. (DOC); Meusbom-Marsh, Stefani L. (DOC) 

Cc: Lindell, Katrina R. (~OC) 


Autumn, Katrina has reviewed and approved the below policy that has incorporated 380.100. There 

are some formatting issues but am not sure if you want me to do that or not. Please let me know. 

Thanks, Jane . 

I· 

i 

! 

From: Miller, Merlin K. 'Lin' (~OC) 

Sent: Tuesday, February 17, 20098:56 AM 


Cc:.. Meusborn-Marsh, Stefani L. (~OC) 

5/13/2009 

PDU-6655-3 000133 .

----_.--_........_.-.._._---------_.._......._-...._... ---_.__ .._-----_._..-_... 


Page 5 of5 

Subject: 


Katrina/Stef, a couple more comments made in red in the attached .. 



Sent: Friday, February 13, 2009 2:22 PM. . 

To: Lindell, Katrina R. (DOC); Witten, Dell-Autumn W. (DOC); Miller, Merlin K. 'Lin' (DOC); 

McKenzie, Jane M. (DOC) . 

Subject: -380200 Community Supervision of Offenders 

«File: 380200 CommunitY Supervision of Offenders.doc ». Katrina - H~re is the policy 

after having gone through my Simplification and run past the union, the policy owner, Lin and the 

RA's for comment. I have also combined this with 380.100 Offender Supervision Status. So that 

policy will no longer exist. There was· discussion about the Medicinal Use of Marijuana being . 

included in this policy - I really do not think it.belongs here, but am not sure just where is should gothis 

is the policy the AS put it in so I left it here. In the future when the annual review is done, 

maybe there should be some consideration of placing it in the 320.155 Violation Policy Also the 

other area that cauSes eyebrows to lift is the Duty Officer Coverage sectionit really does not . 

belong in this policy but where does it belong. Lin suggested 370.100- unfortunately, that poliC;y is 

just being developed.··· . 

Autumn- This is on to you - I am keeping all of my notes for reference on this one. Please also 

see the above as you may want to switch some things around .. 

Lin-. Please take one last look to make sure this all makes sense, please .......... ' .. .it is all running 

together on me now. 

5/13/2009 

PDU-6655-3 000134



P.o. Box 41100' Olympia, Washington 98504-1100 

January 26; 2009 

660" 

De~Mr._· 

Your Medicinal Use of Marijuana request was received 011 January 20,2009. Upon review by the 

Department of Corrections' Health Services physician, your request has been denied. . 

You may appeal this decision by sending your written request within J5 business days of this letter, 


Karen Daniels, A~sistant Secretary 

Commumty Corrections Division 

,Department of Corrections ' 

P.O. Box 41126 ' 

Olympia, WA 98504-1126 

Your request must provide additional infonnation that was not included With your original request. 

Appeals. that do not contain new information will be denied. You will receive a response to your 

appeal request within 30 days of receipt. ' , 

~~ 

Karen Daniels, Assistant Secretary , 

Community Corrections Division ' 

KD:md , 

cc: , JeffFrice, Community Corrections Supervisor 

~~ ____--,-,B.eth8.n..y_Grml:es.-CommUnity_Co:o:ections-O.fficex:x:.._____________----.,----'--- 

FielclFile , ' 


James Reuther, M.D. 

Northwest Behavioral Medicine 

3400 Main Street ' 

v,ancouver,'WA 98663 

"Working Together for.SAFE Communities" 

PDU-6655-3 000135

.... #"""" .... 

'l~ STATE OF WASHINGTON 

~~: DEPARTMENT OF CORRECTIONS 


cco: 


~£c- . . E.lVI;:: '--, 

JAN 2-0. 20U~ 

Dept. or (;ar . 

Health Serv~otlons 

- ICes 







the Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs; . 


been prescribed. The below verification is to determine the legitimacy of their claim. Thank you in advance for your 

assistance. If you have questions please feel free to personally contact the Medical Directorof the Department at (360) 

725-8700. 

1. Is this patient uf)der your care . 

2. Are you pr.escribing medical' marijuana for his patient due to a diagnosis of Acquired 


a. If the answer to question 2 is "Yes:', does he/she have anorexia 

b. If the answer to question 2a is "Yes", does he/she have weight-loss 

~es 

DYes 

DYes 

DYes 

DNo 

~o 

DNo 

DNa 

3. Are you prescribing medical marijuana for this patient due to nausea and vomiting associatecj 

with cancer chemotherapy 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional 


DYes' 

DYes 


duration): . 

~o 

ONo 



use of the oral synthetic formulation of marijuana. If the Department authorizes this patient's 

use of medical marijuana, will you be prescribing only the oral synthetic formulation 

DYes 


Department with current and future information related to this issue. Do you agree to notify ~s 0 No 

---ttAe-E)€I:l·ar:tFr-leAt!s-MeQ.iGa.l-b)'i~ector.-of-ar.:l~'-cbangesjr.L)i.o.ur...aQs.w..er~b..o~e ...,-_________________ 

Prescriber's Name (Print) Prescriber's Signature . Date 

License #: 

License type: 

Prescriber's Address /t()() /If1c.,';" s1: #;: -:s 0:2 Phone Number 

V ~V1W'V




WashingtC!n State Department of Corrections 

PO Box 41123 

Olympia, WA 98504-2113 


I have revie~ed this verificatiofl: ~~d find that use of medical marijuana by this patient 

" (check one) lOis IB is not . 

,. consistent with DOC Policy_ if 0 ./.' . . 

ail •• ut- ~~ 



Date 



1. Email your finding above to the Assistant Secre~ary for Community Corrections 

2. File this form and the accompanying Release of Information in Liberty as a Community Corrections Health Record. 

State law (RCW 70.02; RCW i0.24.105; RCW 7/.05.390; and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prolribit disc/ostlre of 

tlris in/ormatiOIl witlrout the specific i


From: 


Sent: 

To: 

Tuesday, December 09,20089:31 AM 

Ohman, Holly L. (DOC); Ohly, Frank C. (DOC) 

Subject: FW: MM Authorization Request 

·FYI- 

This offender's request was dened. 





7345 Linderson Way SW 


(360) 725-Cl796 


From: 

Sent: 

To: 

Subject: 

Hammond, G. Steven (DOC) 

Monday, December 08, 2008 4:39 PM 

!:Janiels. Karen R. _ 

MM Authorization Request 

No~ consistent with DOC policy· 


Director of Medical Services 



POB 41123 

. Tumwater, WA98504~1123 

360-725-8700 

1 

PDU-6655-3 000138


. ~tors.,. 

t' "- 

1 n'I"Il' \, STATE OF WASHINGTON 

iI' ~ if DEPARTMENT OF CORRECTIONS 



I 

I 

I 

a. 

b. 

3. 

I , 

I I. 

I 

I. 

I i 


By state statute the 'Washington State Department of Corrections is charged with the responsibility to supervise some 





including marijuana. This' offender has claimed that they' have a condition for which the med icinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you ih advance for your 

asosistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. 

1. Is this patient under your care .J~Yes DNo 


Immunodeficie.ncy Syndrome (AIDS) . 

If the al1swer to question 2 is "Yes', does he/she have anorexia 

If the'answer to question 28 is "Yes·, does he/she have weight loss 

Are you recommending medical marijuana for this patient dlje to nausea and vomiting 


DYes 

DYes 

DYes 

DYes 

a. If the answer to question 3 is ·Yes", has the patient failed to respond to conventional . 0 Yes 



duration): . 

.gNo 

DNo 

DNo 

DNo 


4. 

a. 

If you answered "No" to items 2 & 3 above, what is the reason ypu are recorpmrnding medicin~1 use of 

marijuana d' . tJ,:tr..JJ.:..5tl(w.(~ 

I

" \ 

Prescriber's Name (Print) PreSCritl'ey:s Signature Date' 

License #: ./fPr.., ,/n'O /JlJ't) ))J..y() License type: ... ro!.!....l;~'--___________ _ 

Prescribers Address '4.6) ,eden;" due. ttv-::f;;';;2o! ' Phone Number (3(0) fr'6,WI 

, / ~"ta/l\e~ WA- ..9.PJIb ' 

PrElscriber: please return this form and the patient s Release of Information to: 

Medical Dire'ctor 


Washington State Department of Corrections, 

PO Box41123 

Olympia, WA98504-2113 

To be filled out ,by DOC Physician: 

I have reviewed this verification form and find that US~Of edical marijuana by this patient 

, (check one) lOis (]1s not J 

cotis~,nt with D~~ Policy. , , ,":L ' 

a-S(.tv~ t~~vw~'~'V 


ol~-~, 


Date 

'Instructions to DOC Physician: 


1. .Email your finding above to the Assistant Secretary for Community Corrections 

2. File this form and the accompanying'Release of Information in Liberty as a Community Corrections Health ,Record. 

I, State law (RCW 70,02; RCW 70.24.105; RCW 71 ,05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part'164) prohibit 

disclosure of this infonnation without the specific written con\ient of the person to whom it pertains, or as otherwise 


' 

i 

I 

i, 

DOC 14-053 (Rev, 7131/08) DOC 380.200 

PDU-6655-3 000140


From: 

Distefano, Monica J, (DOC) 

Sent: Tuesday, December 09, 2008 8:~1 AM 

To: 

Subject: 

Jack W. (DOC) 


FYI- 

Mr._ request has been deni~d. 



Kare'n Daniels, Assistant Secretary 

Community Corre~tions Division 



(360) 725-8796 


From: 

Sent: 

To: 

Subject: , 


Monday, December DB, 200B 4:37 PM 

Authorization Request 

Notconsistent with our policy 

G. Steven Hammo,nd PhD, MD, MHA ' 

Directbr of Medical Services 



POB41123 " 


360-725-8700 

1 

PDU-6655-3000141

Nov, 26, 2008 4:39PM CBR Medical Inc, No, 2426 p, 2/5 

, , 

f~ STATE OF WASHINGTON 

• !< ~ DEPARTMENT OF CORR~crlONS . 


/lar~ 

OFFFeNOER Le. DATA: 

To be filled out by Prescriber; 


By state statute the Washington State Department of Corrections is 'charged with the responsibility to supervise some 

offenders after they have been con~icted' of a felony. The above named patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead tb their criminal 

behavior. Often illicit drug use is a contributing factor in an indiVidual's oriminality. Accordingly ifs usual that the court or 



been recommended. The below verification is to determine the legitimacy of their claim, Thank you in advance for your 

nnnintnnnn If lin! r hnl In m Inrtlnnr nlnri fiil hi tn nifinnililir rnntilrt tnr Mrrlirn;1 niffmtnr of thfi nftDftrtmftnt ~tl f~iQl 

::I. Arc you rooommonding m"dlc'ill m;;rijllaml fnr hi .. I'lAtipnt rllll" to A rlinono~ifl of Am;juired 0 \ 

3. 

4, 

i Q ~ 

Immunodeficiency Syndrome (AILJS) '. II''' . 

a. If~e answer to question 2 is ~Ves', des helshe have anorexia . . ~rfJo /~ 

b. If the answer to question 2a is "Yes", does 11elshe have weight loss G-¥es---B-oNo >~ 

. . 

Are you recommending medical marijuana for this patient due Lo nausea and vomiting 

a~sociateo with cancer chemotherapy 

a.' If the an~wer to question 3 is "Yes", has the patient failed to respond to conventionsl 

DVes 

~~~ 

B~o,'1,41' 

antiemetiC treatments . "7' ,r 

b. .If the .an~wer to question 3a is "Yes", pleas~ d~be what those treatments were (medication, dose, 

duration), . . '. .;v;ff' '. 

. c. WMt is the planned ,,,,OOule of cn.~' 

.. ~. /It 

If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana 

,a,.&..'\ ~~. \- .S\,- '~'f.\.

, 

\ , 

Nov, 26, 2008 4:39PM CBR Medical lnc, No, 2426 p, ·3/5 

//~ '-\-,:.': "".:. c) \ ,'\'...... 

pre~~rrn:r(Print) 7""'· ."'~ 7-'. --- 

License #: ,:.':' f.' ~"""'-1 '\'-\;( _,' .. _ .. __ .~ ensetype:. . •. ' (~~J)~ __ ---,,.-__ 

, ... -..... "...,... ) V\-.,.·""I\.(

,_._ ....... __ .. _._.- - ..... ----.. -.. . 

J . Nov, 26, 2008 4: 40PM CBR Medical Inc, No, 2426 p, 4/5 

I 

i 

Documentation of Medical A~lthorization to Possess Marijuana 

. for Medical purposes in Washington State 

PATIENTNAME;.:~--:_· _:...... __ _ DATE OF BIRTH: _980 

I, Antoine Johnson ____, ama physician licensed in U18 State of Washington 

and I am tJ'eating the above patient for a terminal iIIn,es..or-ajdebilitating condition as defined by 

RCW 69.51A.010_ '.,. I . 

I have advised the above named patient about .. th·e potentiaVrisks and benefrts of the medical use 

of marijuana. I have assessed the above named patient'::d'rledical history and medical condition. 

It i!::! my mecHcal opinion that the potenfia.!.Ij·enefits of the ~edical use of marijuana may outweigh 

the health risks for this patient" ./ 

J :" 

Physician Name: ~.,0-rtoine:....::;']:..:o:.:..:h;.,:.;ns;;;::o.:.:.n ___/_ WA License NUrllber: ___ M_D_O __ OO __ 3 __ 9 __ 0_48_ 

PllYsician Signature: __ ---:-___ ' /' _....:..../_.,.",.., .::.,.,,~-:--'-6~;e; 

08/24/2008 

This recommendation expir~~ on: 08/24/2QO£'/..... ' 

/


From: Distefano, Monica J. (DOC) . 

Sent: 

Tuesday, December 23,200812:22 PM 

To: 

Hub~); Young, Dianne M. (DOC) 

Subject: FW: ___ mm request . 

FYI 




Community Con'ections Division 



(360) 725-8796 


From: 


Sent: 

Friday, December 19, 2008 9:58 AM 

To: Daniels, Karen R. Monica J: (DOC) 

Cc: 

Subject: 

mm request 

Mr _ 

case does not meet o'OC criteria for approval of me~ical marijuana. 


Chief Medical Officer 


.Department of Corrections 

. POB 41123 


360~725-8700 

1 . 

PDU-6655-3000145

I 


..# ....""..'.~ 

, I[J£ f ~~~~~~~S~~NC~~:ECTIONS 











assistance. If you have questions please feel free to personally ~ontact the Medical Director of tr'e Department at (360) 

725-8700. 

1. Is this patient under your care ~Yes' DNo 


Immunodeficiency Syndrome (AIDS) ....',,' . . . 

a. 

b. 

If the answer to question 2 is "Yes', does he/she have anqrexia 

If the answer to question 2a is "Yes", does he/she have weight loss 

DYes~o 

DYes DNa 

DYes DNo 



·a. If the answer to question 3 is "Yes·, has the patient failed to respond to conventional . 


b. 

DYes 

DYe~ 

If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose, 

duratioQ): . . 

DNo· 

c. What is the planned schedule of ch(7}motherapy 

4. 

If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana A\JtONoM\C- N€V~~A"G'Ay ~""~ C~{l.t)N\( /Dt.~!f."ITA.tJ'4h 

(f\VS-\'-VlO Sl('~l~"t-~(. . [:)~JA/'" . 

a. Please provide evidence published in a peer-reviewed scientific publication to support the medicinal use of 

marijuana for this purpose . ',-- A "TV f:) . 

------------'-. 5-tte-~C-W--b-£f ... -'S-~tl-(t/ .. 'O:.....--L~ .. ------ 

. . . R

1'-" 

I 

~M~! s:,~}::::!l':I.o;:L;G-~l...=---,,,,,,K.os~=F:.r-!=---.:.;r,-----,-,,IIC.=L.L.=:J,--------Q,-----,>-,~ q . ~ 

I 

I 1-) t-06 

Prescriber's Name (Print) Prescribers Signature " Date 

License #: (J~ O

Documentation of Medical Authorization to 

Possess Marijuana for Medical Purposes in Washington State 

Patient name 

Date of birth --=-.*'6 

I 

!. 

· Under Washington. state law, the use of medical marijuana is now permissible for so me patients 

· with ter!TIinal or depilitating illnesses. The law regulating this (RCW 69.51 A) allows physicians to 

advise patients about the risks and benefits of the medical use of marijuana. The medical and 

· scientific evidence supporting the use of medical marijuana remains controversial in the medical 

community. Not all hE:alth care providers beUeve th~t medical marijuana is safe or effective and 

some providers feel that it is a dangerous drug. According t9 the Washington state law, the ben- 

efits of medical marijuana may include treating nausea and vomiting from 2hemotherapy; AIDS 

wasting syndrome; severe muscle spasms from mUltiple sclerosis !=ir other spasticity disorders; 

i . 

I' 

I am a physician licensed in the State of Washington. I am treating the abve named patient 

for a terminal iilne~s or debilit~ting condition as defined in RCW 69.51A.01 O. I have advised the 

above named patient about the pqtential risks arid be1efits of the medical use of mqrijuana.1 have 

assessed the aboye named pat.ient's medical history and medical condition. It is my medical 

opinion that the potential benefits of the medical use of marijuana would likely outweigh the 

health risks for this fatieot. .' ~.. . . . '. 

~~~ .. ~o~ S 

Signature of physician . ~ 'Q:tl\ef; p.., 'S-1: 

, . lC a 

. . (1'\ (> ~p ~ ~t_. 

Printed name of physician ~c.~.A. 't l ~~ Src ~cc~6 L~' 

Risks and ben!!fits of medical marjjuana 

, . seB1~' 3/7/0 ('[ . 

, r-f2 

! glaucoma;and some types of intractable pain. Some of the risks'of medical marijuana may in- 

' 

elude possible long-term effects on the brain in the areas of memory, coordination' and cognitioni 

\ 

impairment of the ability to drive or operate heavy machineryi respiratory damage; possible lung 

\ ~ __ ~-----=c=an=c=e=~=.a=n~d_p_h_y_S_iC_a~lo_r_p=s=y=C=hO='=O=9~ic=a='d=e=p=e=n=d=e=n=ce=.====::::==::==========:====:::=:==~~======~ __ ---- 

This Form provided 0)1 the Washington State Medical Association 

PDU-6655-3 000148

OFFENOER 1.0. DATA: 



'--____ , hereby authorize the use or disclosure of my health information 

as describe.d below. The following individual or organization is authorized to make the disclosure: 

NAME: It'c&c>cCr l..~:$("tJj:icwJ / fJ.. O. 

ADDRESS: f (, f2.o t;r 7 

'1CCt-irJ/ (;.I if q 6'101 

I 

I, 

The type and date(s) of information to be used or disclosed is as follows: 

&ofl7,ltcfcJ Doc- ~/!"1 It( ,o§3 A,Jr/ 1fI{/ rVZtrtYidr' /JJ(o/.M!f/iO;J, 

Purpose for disclosure: teJ/tJr./t


From: 

Sent: 

To: 

Cc: 

Su~ject: 


Thursday, November 13, 20084:14 PM 

Escobar, Magdalena 

Pev~y, Mac B. (DOC) 

ical Marijuana Request 

FYI 





7345 Underson Way SW 


(360) 725-8796. 


From:· 

Sent: 

To: 

Subject: 


Thursday, November 13, 2008 2:31 PM 

Medical Marijuana Request 

This request does not meet DOC criteria for approval. 





POB41123 

Tumwater, WA98504-1123 

360-725-8700 

1 

PDU-6655-3000150


From: 

. Sent: 

To: 

Subjec~: 

Hammond, G. Steven (DOC) . 

November 13, 2008 2:31 PM 

Marijuana Request 

This request does not meet DOC criteria for approval. 


Director of Medical S6iVic6S 



POB 41123 


360-725-8700 

1 

PDU-6655-3000151

11/06/2008 13:05 

- 

PAGE 

./"""-1. 

II> .~ 

11'RIr'1 STATE OF WASHINGTON 

~ DEPAR~ENTOFCORREC~$ 


OI'FENOER 1.0. OA.TA: 

El4l08 

. Ta be fiiied ouf: by F.~ribej": 

Dear Prescriber. 

By state statute the WashingtO!1 State Department of. Corrections. is charged with the responsibility to supervise some 


Department. Supervision is designed to help the offender avoid those environments or situations tha.t lead to their criminal 

behavior. Often illicit drug use is a contribUting factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Correctiofls will impose a condition of supervision that:the offender not use, or possess illicit drugs, 

including marijuana. This offender has clairood that they have a condition for which the medicinal use of msrljuana has· 


assistance. If you hcwe questions please feel free to personally contact the Medical Director of the Depal1ment at (360) 

725-8700. 

1. Is this patient under your care ffYes DNa 

, 

. 

I 

i 

I 2. Are you recomm.ending medical marijuana. for his patient due to a diagnosis of Acquired. 

o Yes B'No 

3. 


a. If the answer to question 2 is "Yes·, does he/she have anorexia 

b. . If the answer to question 2a is -Yes', does he/she have weight loss • 

Are you recommending medical marijuana for this patient' due to nausea 'and vomiting 


a. If the answer to question 3 is "Yes·, has the patieRt failed to respond to conventional 


Dyes 

DVes 

o Yes 

.DVes 

b. If the answer to question·3a is ~es·, please describe what tho~e treatments were (medication, dose,. 

~~~ . . . 

DNa 

ONo 

gflo 

ONa 

11/06/2008 13:06 ·111111111111 PAGE 05/08 

" h 

Prescriber's Name (Print) Prescriber's Slgna!;ure -Oate 

Ucense#: 

License type; 

prescriber's Address 

v-rA 

I" 6 .., ~ _ p ~.,.r-; c:·."...,.....J 

,-/0"3 Phone. Number (ji .f" J) e s ~ - "2....6 6 6 

prescriber; please return .thls form and the patient's Release of Infonnation t~: 




PO Box 41123 

Ol~pia; WA 98504-2113 



Physicilan's SignabJre 

Data 


1. Email your finding above to the Assistant Secretary for Community Corrections . . 

2. File this form and the accompanying Release pf Information in Uberty as a Community Corrections Health Record. 

PCP._._ .._.______.___ lnilials-_ .. 

Mil., ....:___.••___.______...________ Ii1iri1-lls_· -. 

. RC _.__________.•.__..-c-_Initlells._.._ 

-----·-----·------·-·-----·-·--·---·-pcc.~__.._:-.--...._._..._,.....__ !nitial~l._.__ 

Enc# •._____ 

.•.-"'-------. 

PCP'. ____"__.~~._..... ~_ ..._.._·_·_·_~..'"·~·__· 

S('j~n (J..at{:=:~..__....... ~_ ..._......_~~........__,'"'.,..."'.. l nfiif.I.!~1 ,.:-....._ .. ~ 

. Doc Type. ____. __...;.--~------ 

Stat" law. (RCW 71)

I:--- 

j 

! 

-_. 

Distefano, MonicaJ. (DOC) 

From: 

Sent: 

To: 

Subject: 



Fix,~ertA. (DOC) 

-F~mm request· 

FYI 





7345_ Linderson Way SW 


(360) 725-8796 

mjdistefano@d9c1.wa.gov 

From: 

Sent: 

To: 

Cc: 

Subject: 


Friday, December 19, 2008 9:55 AM 

_ 

Daniels, Karen R. Distefano, Monica J. (DOC) 

request 

Md ••• II::ase does not meet DOC criteria for approval of medical marijuana. 




Department of Corrections. 

POS41123 

_ 

TUIDwater, WA 98504-1123 - 

360-725-8700 

- ! 

1 

PDU-6655-3 000154

)'- '.--'-'.~ ~ ..- '........ ~ .... ~-.. - ~------.- ..- ... . 

Dec. 

. 

10. 2008 1:33PM CBR 

~ 

Medic.al .Inc. 

No. 2605 P. 1 


Spokane, INA 99202 

~: .11.{t2L1Lc:£.~ 7J ~'ii~ k i II Q 

~.~:C .. ::;3, (eC) ,:: $-'% (p ::-OJ S'::L. 

.~h~~!~ ~5 it'. q ,~., '1;~ ~',- f 7. 9 (.. , 

~~ .. fhd .. __ 2J JI.II!:i..2 . .__ .. ~~ 

o Plea!S(~ ,Comment 

o Pleaso Reply 

.-~.-.,-.-. 

. ' 

·Comm~l'Its: 

q ( 

f .::> 

.. II:.I,' 

::f f jd CA 

')1 Q' V"f~ 

~~. -/Cf ... -~j U t,' 'v'l "., 

f!j/..) e. C;j"-(' c') ft 5 

/ ' r> I I'" .. ~ p --f o 

fl, e dr- ~

Dec .. 

l0. 2008 1:34PM CBR Medical Inc. No. 2605 P. 2 

/'...... ~ OFFE~OCR I.D.IlATA; 

f f STATE OFWASHINQTON . 

OEPA~TlIIENT OF CORRECTIoNS 


as described below. The followir:tg indMdual or organization is authorized to make the disclosure: 

NAME: (~ B t< At!) J,. c ,"- / XI".., (' . 

ADDRESS .." . I (.- .!.. -"4 .... ". , .11" 

: -') I :::J .. c-':, . .......':,LI Q ')J /::1 '7 q ~N~ 

"3f:·h:.'!:a}l 17 " /.c 9$ (.71 Z. () :2 

I~ • -.. / ----- 

, 

Th~.rpe a~d ~ate(s) of information, to be ~~ed or disclosed is as fOllOWS;. / , ~ _ ,•.. 

J/f"cit C",'''''''''{ 

.jl(Lr· 

.AlatCJ.l..~l,.it;t nA. A'l-z'il-Irrzt'rctf (; (jv/ 

K {} (() c(·{Z U(-y-; A'-_____ . ______ 

....:....-__ 

- ..-.... ~------------ --------------_ 

........ 

PurposefordiSclo$ure: ·:Jl't..i(.7"'-;;:~·;, 7)··) , !J,.J.tJ,d.' • ..,_. "-""( "'.. }.,_. 

.."t.{e (fi"~.•. L . fi1(.~'1 "

V.., ... , IV. LVVV I'JiIIYI VUI\ III\" U I \"U I .1 /II", 

OFFIiNnR< 1.0. DATAnv. 

LVVJ 

I, J 

C;:TlITI< n~WA'nll~lr.Tnlll 

DEPARTMEMiOF COR~ECjJONS 


. . 

r'~pY 

.befllJedOutb.. Ỵ c;,..=..co=."=-" --_. -----~.'-..--,.- 

~:--' ___-'-t~~" " ,--''''f1[1f:*_- 


Dear Prescriqer,. 

Oy :,ldlt::: ",t.:1tuL.. IIle W ..",liilll;llv" Qlate Dcpa"b·,' ....,\[ ~ Cor~iQn" b e"~rs~d ·,... i~" the rcoponoibility to ouporvioa t;omwt;:1 Lu ~u .... liull J it> "V..,,,", Jug6 r.~/llIk

~ec,.10, 2008 1:35PM CBR Med ic"a 1 Inc, No, 2605 p, 4" 

/'- 

I~ 2 ,-' 

,t,/ 

«'i J" .... \..-~ 

DllltE! .---- 

License #: _., Ji!J), co 4-'

.... "-'" .. __ . - .-.-... -... ----.--.-.. ,~~ ... _-.-.. "~-'--'-"'" 

. D.ec .• 10. 2008 1:35PM CBR Mdical Inc. No. 2605 P. 5 

Documentation of Medical Authorization to [·'ossess Marijuana 

for Medica[ Purposes in Washington State 

PATIENT NAME: --' _ __.II •• DATE OF BIRTH:~ 

Ir Dr. Mohammad H. Said • am a physician licensed in the State pf Washington· 

and I am treating the above patient for a terminal illness or a debilitating condition as d,,!tined by 

RCW 69,51A010. 



It is my medic.";!1 opinion that the potential benefits of the medical use of marijuana may outweigh 


Physician Name: _ ...... D'"""r.._M_o;oo.h""'a"-"m'-A m ...;;a;.;od_ 

n 

..... ~!S.'id r'57;:"ffibec 

6 

Physician Signature: j/': ~ c::..) ...... V\.,. Data: 11/16f2008 

This recommendation expires on: 

Oif16/2009 

MD00018311 

Risks and benefits of medIcal marijuana 

Under Washington law, the use of medical marijuana is now penn is sible for some patients 

with terminal or debilitating illnesses. The Jaw regulating this (RCW 69.51 A) allows physicians 

to advise p·atients about the risKS and benefits of the medical use of marijuana. 

T!o\e Mccliool ::lnd "",ion~ific Q\lirlr.mrp


From: 

Sent: 

To: 

Subject: 

Attachments: 


Monday, December 01, 2008 10:02 AM 

Oglesby, Jcn D. (DOC) 

MX-5500N_20081201_095313.pdf. 

MX-5500N_200812 

01_095313.pdf C ••• 

Gocd morning, Jon! Mr.~enialletter was put in outgoing mail cn We(jnesday (probably actually gcing cut tcday.) .. 

.' " . 

Here is a ccpyfor your reccrps. 

Please let me know if ycu have any questions! 

Monica. Distefano. 

Executive Secretary to. 


Community Correctio.ns Divisio.n 

7345 Linde~so.n Way SW 


(360) 725-8796 

mjdistefano.@doc1.wa.g.ov 

1 

PDU-6655-3 000160

",'. 



P.o. Box 411 00 • Olympia, Washington 98504-1100 

. November 26, 2008 . 

Spokane Valley, W A 99212 

D~arMr_ 

. . 

We received the request from CBRMedical, Inc., on November 19, 2008, to appeal our 

denial of your request to use Marijuana medicinally while you are under the jurisdiction 

or supervision of the Department of Corrections: .. . 

In the interest of public safety and protection of the community at large, I am denying 

your request to use Marijuana for medicinal purposes during the period oftime that you 

are under supervision. 

I would encourage you to continue to program in a positive manner, following the 

direction of your assigned CCO and your conditions of supervision. 

.. n 

Sincer~ly> 

! ..' 

Dame sistanl Secretary 


KD:md 

cc: Jon Oglesby, Community Corrections Officer 

Field File 

"Working Together for SAFE Communities" 

t'; ,ecycled paper 

PDU-6655-3 000161 

)

Stern, Marc F. 'Dir Hlth Svc' (~OC) \02: ~ . 

To: 

Cc: 

Subject: 

. :-'\l . 


810~ .. 

Mr. ____- Medicinal Use of Marijuana Appeal 

I have reviewed Mr._ appeal of the Department's decision to not authori~e his use of medical marijuana. 

My review included: 

-The original request form 380.200, undated by the author, with a one page attachment from Dr. Johnson; 

-.~.n email from Dr. Hammond to you indicating that M~. lid not meet medical criteria for medicinal· marijuana (MM) 

use' 

-A 1'6 page fax - presumably an appeal - dated 11/19/2008, including: . 

a cover page (indicating.that the fax doc\1ment contains 6, not 16 pages), 

. a clinic note, dated 11/0212008 

a clinic note with no date 

a 3 page print out entitled "Scoliosis Back Pain" . 

an 8 page print out entitled "Effects of Smoke Marijuana in Experimentally Induced Asthma" 

another request form 380.200, also undated by the author .. 

According to the documentation of th~~1 request, Dr. Hammond determined that Mr. Jseof MM did not meet 

DOC criteria apparently because Mr: ~id not suffer from designated complications, of two DOC-identified diseases. 

From a purely procedural standpoint, the appeal is flawed. First, the appeal request itself, contained on DOC 380.200 is 

incomplete. T[1e required fields, including prescriber signature, date, an¢ prescriber licence number and type are missing. 

The printed name is illegible, but appears to be similar to the physician name on the attached two clinic notes. Second, 

the second clinic note, indicating that Mr._sqffers from a$thma and chronic intractable back pain, is undated, So 

these might have been his diagnoses last week or 20 years ago and no longer active. Third, I question the authenticity of 

the first clinic note date 11/02/2008. Unlike every other practitioner note I've ever read, and, notably, unlike the other clinic 

note in this packet, it's written in the third person. 

From a clinical standpoint J offer the following opinions: 

Fir~t, with regard to Mr._ diagnoses requiring. treatment with MM, the undated clinic note indicates that Mr. _ . 

suffers from "Asthma (spasticity disorder)." No such disease exists. In the remainder of my report I am going to assume 

that there was an error io the report and Mr._suffers from asthma.' . 

Second, the appeal Indicates that tHe reason for MM is that neither Mr. back pain nor asthma are alleviated by 

standard therapies. I have difficulty believing that no other analgesics and no other asthma medications has worked. 

Further, there is insufficient clinical information in the appeal to support either claim. 

As background for the·next few item!" the Department requested from Mr. prescriber 'information published in . 

peer-reviewed scientific journals explaining the medical evidence for the use of MM in for Mr._for anything other than 

the two deSignated diseases. . 

The third opinion, then, is that with regard to Mt._diagnosis of back pain no such scientific material was provided. 

the only information that was provided was a print out on scoliosis-related back pain. The print out is is the text of a . 

question and answer session with a doctor who invented a spine brace, obtained at a website 

(www.scoliosisbackpain.com).This is not a scientific publication nor is it peer reviewed. From an evidence based 

medicine standgoint which is how our grofe..s.§ion trie..s_tQ...lIJ.a.ls~tgp.o_cLc.linlc.aLd.e.cis.i.oJ,l.s.,jll:tasJittle..to_o.o~v.alu.o:::.e ____ _ 

Fourth, even if this publication had scientific value, it is not relevant to this patient. The rint out is on the topic of 

scoliosiS; the information we received from Mr. doctor did not indicate Mr. has sc~liosis. 

Fifth, with regard to the (presumed) diagnosis of asthma, Mr,_physician did provide an scientific article from a 

peer-reviewed journal regarding the salutary effects of smoking marijuana on asthma. However, there are serious 

shortcomings of this article. First of all, it was a study on only 8 subjects. Second, it tested the effect of a single time 

smoking marijuana on asthma. It is well known that chronic smoking (of anything) makes asthma worse, and this is even 

noted in the article itself. Third, the study was done in 1975. There have been tremendous strides in the care of asthma in 

the last 33 years that don't involve marijuana. Lastly, the.article about smoked marijuana is not relevant to or helpful in Mr . 

••• case since the Department would only allow Mr._to use oral, not smoked marijuana. . 

. 1 

PDU-6655-3 000162

!.----.-..:..- -_.- ...--.--.-.. ~. ---_........_....._---_._--_...._--_. 

1 

I i 

I· 

I 

I 

Thus, in conclusion, I do not find sufficient evide~ce of a clinical n.§cessity of marijuana in Mr __ case_ 

Marc F. Stern, MD, MPH 

Assistant Secretary/Health Services Director 

. Washington State Department of Corrections 

Affiliate Assist. Prof" Dept of Health Svcs, 

School of Public Health, Univ. of Washington 

7345 Linderson Way, Sw, Tumwater WA 

Mail: Dept of Cor recti OilS; PO Box 41123; Olympia, WA 98504-2113 

m(stem@t!ocl.wa.gov 

Voice: (360) 725-8700 Fax: (360) 586-9060 

.--'----------------------------'----------.. _------ 

2 

PDU-6655-3 000163

!---.-_..- ..._.. _._....__......._ .. .. 

i 

November 26, 2008 

Spokane Valley, WA 99212 

Dear Mr._ 

I received the request from CBR Medical, Inc., on November 19, 2008, to appeal the 

denial of your initial Medicinal Use of Marijuana V

fit 

• '\ STATEOFWASHINGTON' 

i • DEPARTMENT OF CORRECTIONS 



HOARD, RAZEKIEL 

Date 09/09/2008 

~cco; 

. , ame L-_______________ ---LJ.o:..:~'-'-~..::~-rth------IL.-m-b-e-r ___ -' 



By state statute the Washington State Department of Corrections is charged with the re.sponsibility to supervise some 




the Department of Corrections will impose a condition of st/pervision that the offender not use, or possess illicit drugs, . 



assistance. If you have questions please feel free to peisonally contact the Medical Director of the Depaitment ft (360) 

725-8700. ~ 

1. Is this patient under your care r:;a-Yes D t~o 

~. 

Are you recommending medical marijlJana for his patient due to a diagnosis of-Acquired 


a. If the answer to question 2 is "Yes", does he/she have anorexia 


3. Are you recommending mediG:al marijllana for this patient due to nausea and vomiting 


a. If the answer to question 3 is "YI~S", has the patient failed to respond to conventional 


DYes 

DYes 

Or:Jo 

Q'y"'e~s-.....j.El.....j..lo'No 

DYes 

[].>tees 


duration): '. __.__-- 

~ 

01\10 

c. What is the planned schedule of c~emothera~ 

4. 

a. 

If you answered "No" to items 2 & 3 above, what is the reason you .are recommending medicinal use of 

mad;uana . . JUL 

"-~,"l ~ L~/-/ 

Please. provide evidence published in a pe'er-reviewed scientific publication to support the medicinal use of 

marijuana for this purpose' . \ \ 1 

. XQ.f'f..,c..;,~ 7/"' u·~

I 

J 

i 

Date 

License type: 


Phone Number 

Prescriber: please return this form ~nd the patient's Release oflnformatin to: 


H£;)alth Services Division 


PO Box 41123 

Olympia, WA 98504-2113 


I have reviewed this verif!cation fo!:!!, ~d find that use of medical marijuana by this patient 

(check one) lOis [{dis not . 

cons~~ntwith DOC Policy. .' . ~ . 

. ~S·~ev..lio.~~~.~lILV. ~~ 


Ptiysician's Signature 

(Df/slo8 

Date 

Illstruptiqns. ~o poe P1"!ysician:._ 

When forini~ compiEit~:"" 


. 2. File this form and the accompanying Release of Information in Liberty as a Community Corrections Health Record. 

State law (ReW 70.02; RCW 70.24.105; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infonnation without the specific written consent of the person to whom It pertains, or as otherwise 



PDU-66513-3 000166

Documentation of Me.dical Authori;zation to Possess Marijuana 

for Medical Purposes in Washington. State 


DATEOFBIRTH:~ 

I, Antoine Johnson , am a physician licensed in the State of Washington 


RCW 69.51A.010. . 

I have Cldvised the a~ove named patient about the potential risks and benefits of the medical use 

of marijuana. I have assessed the above named ient's medical history and medical condition. 

It is my medical opinion that the potential ben of the medical use of marijuana may outweigh 

the health risks ror this patient. 

Physician Name: -,--.=.:..:~..:.:.=.:!.!.:..::..;z:..::.::~:....----- 

WA License Number:. __....;.M....;.D_O_0_O_3_9_0_48_ 

Physician Signature: __ ~ __ +-______ . Date: .__-'0;..;;9....;.10;;..;7....;./2;;.;0;;..;0;..;;8....;..-___ 

This recommendation expires on: -/-=.::..:..:..:..::.:.::.. ___ _ 

Risks and benefits of med;cal arljuana 

Uhder Washington law, the use of medical marijuana is now permissible for some patients 

with terminal or debilitating illnesses. The law regulating this (RCW e9.51A) allows physicians 


The medical and scientific evidence supporting the use 'of medical manjuana.remains 

controversial in the medical community. Not all heal.th care providers believe that medical 


According to the Wa$hington State law the be.nefits of medical marijuana may include 


spasTTls from multiple sclerosis or other spasticity disorders, glaucoma, and some types of 


Some of the risks of medical marijuana may inclu.de possible long-term effects of the brain in 



dependence. - 


As this patient's "60 day supply", as stipulated by RCW 69.51A(2)(b), I recommend 24 ounces 

of dried, cured marijuana and as many plants as the patient feels necessary to maintain this "60 . 

------a=a"'"y:-::s=u=pply". . - 

CBR .Medical, Inc. 


.3115 E. Mission Ave 


Spokane: 509-242-8624 

Seattle; 206-774-6493 

Revised 7/07 

PDU-6655-3 000167

Distefano, Monica J: (DOC) 

From: 

Sent: 

To:' 

Cc: 

Subject: 


Wednesday, October 15, 20081:18 PM 

Oglesby, Jon D. (DOC) 

Deg~ 

FW: ___ mmRequest 

FYI 







. (360) 725-8796 

mjdistefano@doc1.wa:gov 

From: 

Sent: 

To:. 

Cc: 

Sub~ect: 


Wednesday, October 15, 2008 12:41 PM 


I have reviewed this request and denied it as it does not meet DOC criteria for approval for medical marijuana. 





POS 41123 


. 360-725-8700 

1 

PDU-6655-3 000168

- 

/ttors.u, . 

OFFENOERLD. DATA: ----- 

~ 

-g ~"[J£' ."\ STATE OF WASHINGTON. 

l> • DEPARTMENT OF CORREC,.'ONS 



I, hereby authorize the use or disclosure of my health information 

as described below. The following ir:divldual or organization is authorized to make the discl;sure: 

NAME: 

ADDRESS: 

Dr. Antoine Johnson/CBR Medical, Inc, 

31151=. Mission Ave. 

Spokane, WA. 

99202 

i. 


All medical history, and other information used to screen offender for Medical Marijuana consideration. 

Purpose for disclosure: Provide DOC with current and future' information related to offender's health status. 

I understand that the information in. my health record may include information relating to sexually transmitted 

infection.s, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also 

include information about behavioral. or mental health services arid treatmentfor alcohol and drug abuse. 


Dr. 'Steve Hammond, Medical Director . 

NAME: Washington ·State Dept. of Corrections 

ADDRESS: 

7345 Linderson Way SW. 

Tumwater, WA. 

98501 

·1 understand that I have a right to revoke this authorization at any time. I 'understand that if I revoke this . 



response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, 

or condition: 1/1/2010 (if left blank, authorization will expire six (6) months from signing). 

I unc;lerstand that authorizing the disClosure of this health information is voluntary. I can refuse to sign this 


information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure' 

of information carries with it the potential for an unauthorized redisclosure and may not be protected by fegeraJ or' 

state confidentiaiity rules. If I have qUI~')tions about disclosure of my health information, I may contact the 

RHIT/designee of the facility: ..' 

~--~------------------------~------------- 

Date 

(Qo_DQ.l~n ifform is not comRlI1~) ___•__(Patient to comQleteL..l _____ 

---~ 

Social Sequrlty Number' te of Birth DOC Number 

L2Li7~'_ Wjof' 

. ~9t:f'0fWi . ate 

Siale law (RCf!' 70.02; RCW 70.24.105,: ReW 71.05.390) andlorjederal regulalions (4'2 CFR Part 2; 45 CFR Pari 164) prohibil disclosw'e 

. oJthis inJormation withoullhe specific wrillen consen( oJllze persoit 10 whom it perlains. Or as otherwise permitled by law. 

DOC 13·035 (05/19/2008) POL . DOC 380.200 DOC 600.020 DOC 640.020 DOC 670.020' LEGAL 

PDU-6655-3 000169



P.O. Box 41126' Olympia. W:lshingloll 98504-1126. 

FACSIMILE TRANSMITTAL SHEET 

TO: 


COtv!PANY: 

FAX NUMBER: 

509-340-2710 

PHONE NUMBER: 

FROM: 


DATE: 

NOVEMBER 19, 2008 

TOTAL NO. OFPAGES INCLUDING COVER: 

6 

SENDER'S PHONE NUMBER: 

360-725-8796 

SENDER'S FAX NUMBER: 

360.;586-0252 

o URGENT X FOR REVIEW o PLEASE COMMENT 0 PLEASE REPLY 0 PLEASE RECYCLE 

NOTES/COMMENTS: 

Please let me know if you need'anything else, M~lissa. 


Executive Secretary 

360-725-8796 . 

PDU-6655-3 000170

' . -... ---.. -- .. -.... --. ----.---. ------.. --......... ---... .-...... -_ .. ---.--......... -.-... -.--._.-..... -. -.--.. - ----.--.-...... -- ..... -... . 

J . Nov, 19, 2008 12:35PM . CBR Medi cal Inc, 

. No, 2321 p, 

Office Offlie D' 

epl.lty Secrist ary 

NOV 19 200B 

. Community 

. Correcfio" 

nSDIVision 

PDU-6655-3 000171

I. 

1 


From: 

Sent: 

To: 

Cc: 

Subject: 

Oglesby, Jon D. (DOC) 

Wednesday, October 15, 20084:38 PM 


Bur~erman, Darron J. (POC) 

RE: ____ mm Request 

No thanks needed. I was curious if you have received papE;lrwork for ••••• yet 

From: Distefano, Monica J. eDOC) 

Sent: Wednesday, October 15, 200Ej 2:26 PM 

.To:Oglesby,~ . 

Subject: RE: ____ mm Request 

Thank you,. Jon! 




Community Corrections Division. 

7345. Linderson Way SW 


(360)725-8796 . 


From: 

Sent: 

To: 

Cc: 

Subject: . 

Oglesby, Jon D. CDOC) 

Wednesday, October 15, 2008 2:25 PM 

Distefano, Monica J. CDOC) 

Bo~ House, Kevin F. (DOC) 

RE:__..mm Request 

Thank you. Offender will be directed to immediately cease using marijuana,. and a UA will be taken to obtain a baseline 

nanogram level. 


Sent: WednesdClY, October 15, 2008 1:18 PM 

To: Oglesby, Jon D. eDOC) 

Cc: Degeorgio~ . 

Subject: FW:~m Request. 

FYI 

MOnica Distefano 

Executiv.e Secretary to 


Community Corrections Division' 


Tumwater, W A 98501 tvIS: 41126 

(360) 725-8796 . 


.1 

PDU-6655-3 000172

From: 

Sent: 

To: 

Cc: 

Subject: 

· Hammond, G. Steven (DOC) 

Wednesday, October 15,200812:41 PM 

,Daniels, Karen R. 

I 

I. have reviewed this request and denied it as it does not meet DOC criteria for approval for medical marijuana. 



'Health Services Division 


POB41123 


1360-725-8700 

2 

, PDU-6655-3 000173



P.o. Box 41126' Olympia, Wushinglon 98504-1126 

October 29, 2008 

. Tacoma, W A 98404 

RE: Appeal for Medical Use ofMarijuaiIa 

Dear:M:r._ 

I have received your offender fIle as well as your appeal for Medical Use of Marijuana 

submitted by Dr. Scott L. Havsy, and received in my office on October 29, 20.08; 

In the interest of public safety and protection of the conimunity at large, I fmd your request 

. for Medical Use ofMariju~a, while under the supervision of the Department of Corrections, 

is denied; . 

I would encourage you to continue to program in a positive manner, following the direction 

of your assigned CCO and your conditions of supervision: 

Sincerely, 

~ 



cc: CCO Lynne. Hudson 

PDU-6655-3 000174


DEPARTMENT OF CORRECTIONS, 

Pierce County Community Justice Center 

eeo Lynne Hudson 

1016 $outh 28th Street. 

Tacoma. WA 98409 

~53-680-2683 (work)' 

253-597-4352 (fax) 

i; ~(M..L.D .Ps 

3sponse: 

\ ' 

:z..t;,3 - G.:So- 2L. S'2:, 

Imber of pages incfuding this page: (4)' 

)m:' LYI:'lne Hudson, CCOS. Tacoma, WA 98409 

is facsmile may contain confidential information intended for the individual or entry to Whom it'is addressed. 

~--"'l'lot-l'eacl,Ge~y-0F-I;Hssemll"late-tl9ls-lnf0rmatioFH:lflless-y0tl-al'e-tlge-acldressee-er--the-~e!'s0IT-reSp6nsible-foF-'-- 

Iivering it. If you receive this communication an error please cal! me, Lynne Hudson, at 253-680-2683. , 

ank Youl! 

' 

PDU-6655-3 000175

leT/li 

od. 8. 

200~) 1: 3BAM 

O/llJVO/JllVn v'l::~.1 nu 

. . . 

Ta~rtt L. Havsy, DO, OAAP~.AX No.1253597~35Z 

No.7218 pP. 1 

.IJUl 

'Oate: CJq4. (.6" CT'fl:, 

To: 'D,,- .. \:z\.e..\I~ts 


DEPARTMENT OF CORRECT10NS 

Pleroe County Commonlty Justice Center 

I 

i> .~ 

~\' 

!teo Lvnne Hudson 

1016 South 28th Street. . 

T~comar WA 98409 Y ~. 

25:3-080-:2683· (work) . . ~ . {~ . 

253-597-4352 (fax:) ~ \ , . 

. . ,\.l \( 

.~ {v\,, . 

. ~. -{at' -r' 

.cy,~~ . 

R.~Sponse: 

Number of p~~s including tliis page~':!SiEi--!L-""'--_ 

. . 

From:. Lyn.ne Hudson. CC03. Tacoma, WA 98409 

.. 

----i-hs-facsrnile~r:naY-~Y-ltain-cor-rfidential-lnfor.matlocl-intended.for-tf:le-indlllld.uaLar:.eotry...to_wholDJt.1S...aridte_ss,7'e""'d, ___ _ 

Do not reed, copy or dIsseminate this Inkmnatloo unless you are the addressee or the person responsible for 

. deflvel1ng It. If you receive this communicatIon an error please call me, lynne Hudson, at 25~680-2683. 

ThsnkYouli . . 

PDU-6655-3 000176

No,7218 p, 2 

p, uu, 

/ ..... ~ 

f~ 5TATEi ClFWASHINGTCN 

DEPAImotI!N'T' OF CORRI!CTIONS 

I.MXI 

Medicinal Use· of Marijuana Verlflcatfon 

OFFalOeP. lo. DATA' 

Dear Prescriber, . , 

By state statute !he Washington state Oaparlment at' Cortectlons Is Qhwged with the r86ponalbllity It) l,Iupervme some, 

offenders after they have be$n convicted of a felony, The above named. patient I!S currenlfyo Under supervision by the 

Department. Suparvlslon Is desIgned to netp the Q/Yender'~VQid th04e environments or situations tI;Iat lead to Ihalr crimina[ 

behavior. Often illicit dfug use Is B. conirill.lting faclnr in an indMdlr.ll's Cf'lmirl~nly. Aeeordlngty It's USIlal1har U1e CQlIrt or 

Ihe OBpartmen~ Df Corl'tlcUooa wtJllm~s.", eondlllon Of aupervision that the offender net u~a, or PDS8E!SS nliclt drugs. 

including marijuana.. This offender has claimed that they have a condrtlon tot which the medlcll'lBf LillI!! of msrijuSina has 

. be;., l'6Ccmmendsd. The belew vd~ 1& !D. detemiine!he legilimeny ofiheir clehn, Thank you. In edvanca for your 

assIstance •. It you have Cluestfona pI$ase 1eel free 10 personBlly cantect the MedlCllI Diraotcr of the Department at (360) 

725>8700, . 

1. Is this patient under YOI!!' eara7 

2, Are you recommending medrcal marijuana for his patient due tl; S dlagnosl~ of Acqu!r.r:I 

Immuncdeficleney Syndrome (AIOS) 

•. ~. If Ihe answer to QUestion 21$ ·Yes', does'he/sh~ have anorelda 

b. If tne answsr.ta qUB!ltlOl1211 Is "Vas', does he/atle hive ~iSht 105$1 . 

,~ 

o Vel! 

elVes 

o Vet 

9. Are you reeQmmending m$aleal marijll8nat'or this pallent due to nausea and vomitIng 

associated with canoer 

DYes 

chemo~herapy ' . . 

iI. If'the emwei' to Cltl811t1an :3 la "YSS·, has 'tile patient failec! to mpond to eonventlonet 

antiemetic lrealmen!s 

' 

DYesb, 

If the answlIlrto qUe$UOI'1Sals "Yea", please describe what those treatments wers'{medicaHon, dose, 

duration): 

• Whol''''.!t'''''_~clwm~ J!!: . 

. DNa 

~ 

CJNo 

DNo 

~ 

DNa 

WYQUanit:fre;./J;;i~£:~~$te~~:;~U~eG~~/~ 

marijuana . • ~ /1 ('I' . ~"U~ 

"I-c:" . trleG G-J ~ fL.I..t.t- 1/ ~ --~ . 

a.. Please provide evidence pUbllshed in a peer-revlew~d clentltle publiCatIon to aup;fttha medicinal tJ.:: .... r:sJ, 

mariJuana for this purp08.e . f'k ~'.:.- i l-t; ~ ~ r""L§'"''''>, 

----,-----~ 'fi~~.---~~-: 

5. Wlie on community supervision ("parole") the Department of Corrections only ilUthort~~ 1M .=.L 

use Qf!he oral 31'11tiletlo formulation IJf marijuana. If tile. Department authorIzes thla patient's 0 Yes f 

use ofmedlcal mariJuana, will you beprescrlblng anlythe oral synthetleform,UlaUOn ,. _. " '. 

6, ihe pa~e(\i's aCCClmpanY/ns ~I$aee of Inforrnadon OIl,Ithonzes)'Ou to provrde lile ' 

DapartmentwHh current and MlIll rnormalioo related to thIs Iss!l6. Do yeu agree to notify 0 Yea Ne 

the Dep~ent's MedlCiI Director of sny chang-as· in your .answers above7 

DOC 1"-053 (RSv.7I3jJOS) 

PDU-6655-3 000177

No,7218 pP, 3 

, UUj 

C81'\SS #: 

license type; 

kQoate 

prescr/bar:' pleass return thll torm.sod the' patienfs Release, of InfCllTlla~n to: 

Mel/loal Dlreetu!' 

Health Servloas Divl$ion 

W;;eh!nGtQn S1Ble Department of Corrections 

PO!3ox41123 

OIY':'Pia, WA 08504-21H! . 

To be fined out by DOC phY.slcfan: 

1 have revfeWlKi 1111& verification 'form and"flnd !hat Use of medical marijuana by this' patient 

, (ohsO!: or.e) I Llle 0-11 not " " " . 

00 "~with DOC Fa/loy. v 

lnatructiuns to DOC ~hpjciam 

When fllnn Is complete: " . 

1. email yourfindlngabovetotheA.lllItantse«etar.l.ror CommunitY Carrections 

2. FDe th,is funn and the accompanylng ~ease of lnform~tion in Liba,"t't as a Commlll1lty COrrectlomr Heafil1·Reeertl: 

" 

Slate law (RCW 70.02; RCW 70..2ol.1Od; Fl.eN 11.O~.~1 JIndf.r fiodan!l r'egulall .... (~2 01'1'1 PlII'I 2: 41 ePR Part 1114) pRltJibit 

lIisclasllre Qftfli& infimna6o!T wil/tQ\lt the speclli" wntten callSlnl of th8 psrSMIIo vdtom It paJUlnI, of";' ethllrwl1f. 

ponnl1ld byt.;w. 

COO 1~05S (R81I. 7131108) 

DOC

:t: ' P. Ul )j( 

:I: . • TRANSACT ION REPORT )!( 

:r OCT-08-2008 WED 12: 43 PM )\( 

':t: :it FOR: COMMUNITY CORRECTIONS 360 586 7274 * 

:it * 

:it )!( 

:it RECEIVE :it' 

:it 

DATE START SENDER RX TIME PAGES TYPE NOTE' Mlf DP * 

)!( :I: OCT -08 1.2: 43 PM 12535974352 43" 4 FAX RX OK . * 

*. :I: 

:it*)!(u*:itUUU:t:U:it*lKlKUlKlKlKlK*U***lKlK********n**nlK**ulK**lK**U**lK*lK*n**UlK)!(lKlK*lKlKU********U**U**** 

PDU-6655-3 000179

OCT/OS/200S/WED 01:39 PM Tael FAX No, 12535974352 

P, 001 


DEPARTMENT OF CORREcnONS 

Pierce County Community Justice Center 

eeo Lynne Hudson 

1016 South 28th Street. 

Tacoma. WA 984Q9 

253-680-2683 (work) 

253~597-4352 (fax) 

~sponse: 

ll~Ag 

\ 

z.:;..3 - @- 2.G.B 

Imber Pf pages including this page: M 

)m:· Lynne· Hudson,. ee03. Tacoma, WA 98409 

---is~faQsF!1Ue-maY-QOFltaiA-Gonfidential-lnformatlor-J-iJ:ltenGled-for-.tf:te-iFldi¥idua~or-er-lt~-tQ-Whorn-it~ls-addr.essedl.,. -- 

. I not read, copy or disseminate this Information unless you are the addressee .or the person responsible for 

five ring it. If you receIve this communication an error please call me, Lynne Hudson, at 253"680-2683. 

ankYou!! . 

PDU-6655-3000180

OCT/08/2008/WED 01:39 PM Tacl . FAX No. 12535974352 P. 002 

:::CT/Pct. 8. 

200~\411:38AM 

:,: ,01 ,,,

OCT/08/2008/WED 01: 39 PM Tael FAX No. 12535974352 P.003 

i 

No. 7218 P. 2 

p, UUl 

'I 

I 

I 

", ..... " 

~ ~ STATE OF WASHINGTON 

..., ~AfomlI!NT OF eORfU!CTIONS 

Medicinal Use of MarfJuana Verlflcatlon 

I 

I 

! 

Dear PresCriber" . 

By state stafuls the Washington state Department of Cnrtectfons Is aharged with Ihe rnponslbility 111 ~1ipervise some. 

offenders after they have been convicted of a felony. T{le above named,patient Is currenj~ under supervision by the 

Department. Supervision Is dealgned 10 help !hI! oIl'ander avoid thOle environments or eltuaUonll that lead !o !heir criminal 

behalliol'_ OIIen illicit dfug use Is a contriJlJlinl1 facIDr in an individtr.ll's crlmil'laltty. ~Clrdlngly It's oBtl'Si 1hat lhe co~rt or 

Ihe Capartmen~ of corr&etfona wllllmPOs. a condlUon of aupurvi5ian that the affendernot U!le, or possess Ulicit drugs; 

including marijuana_ This effendiiii' has daimed thaf they ttave a' eolid!t1on i'ot which lhe medicllil! Lila of maiil~nil hiS 

been recommended. The below varfflcatimi& to determine 11:18 legitimacy of iheir claim. Thank you in advance far ytlur 

assIstance., It you have Questfons pi$l.se feel free 10 personally contact tile Medlcsl Oil1lotcr of the Department at (360) 

725>8700. 

1. Is thfs patient under yo~r care 

2. ' Are you recommending medical marijuana for his patient due til 9 dlagno$1$ of Acl:jull'ld 

.. Immunodefir::ieney Synclro\'l19 (AI~) 

lil. If 1he answer to QUe$Uon ~ Is ·Vest. dr;ie$ he/she. have anorexta 

b. If tns answer to lIues!JCI1 2. III -Vas", does he/she have weiSht loss 

3, Are you recommending m&dlcal mlil'ijl.l&na (or this paDant due to nausea and vomiting 

associated wfth cOIIlCer chemotherapy • '. ' 

ii. ,fflhe iinllwer til ql'Jestlan 3lB '"(8S·, has the patient failed to respond to eonventlone! 

~ntlemailc iraalmen!iI 

~ 

DYes 

ClYes 

DYes 

C1Yes 

DYes 

D. If the aoewerto QU8$!IOh 3a 15 "Yes", please describe what those Ire;;lments lIIIere (medicalloo, dose, 

duration): 

' 

[JNo 

~ 

CJNo 

DNa 

~ 

DNa 

c. What is thlnned sohedule of chem~fherapy ~.. " '., " , . 

rtIrJ o./~,,JL-· +f~J.--r-,~, ~4~ 

4. If you an!i "Ng" 'a Items 2 & 3 above,. what is the reason you are recommendlng inedlclnaluse of 

marijuana '¥-~ ~ fte-GB,rl~ fv~ 

a. Fiease provide evidenee published ~ a peer-revlewed 15clenllllc publication to iUP;ft the medlolrlal IJ.~~! j, 

marlluana for this purpose7 TJ'L,J.,...... ~ 'IJ IT f4 ~ 4"''''>. 

------, ~-~l7-~-~ 7--1--'----, --- 

. 5. While on community supeMslon ("parole") the Department of Corrections only ~uthorl%e' 1he .;,../._ ' 

use of !he oral sl'"thetlo formulation tri'marijuana_ If tOe Department authorll:ea thIs patlenl's D Yes V 

use of medk:a/ marijuana, will you be prescrlb!ng only the oral synthetic fomiulaUon 

6, Thepat1en~s accompanying ~Iaaee Of InformaUon liIUthorizes you to proYlde the .- 

Oeparfmentwith currant and Min i1furmation related to this Issue_ 00 you agree to notify, 0 Yes' No" , 

the D~ent'll Medle;i Olrector of any changes in your answers above . 

' 

DOC 14-053

'.-, 

I 

, i 

i 

OCT/OS/200S/VIED 0[: 39 PM Tael· FAX No, [2535974352 

No.7218 P P. 3 

, UUj 

P, 004 

license type; 

Prescrtber's Addreea 

Pha~ Number. 

presc:l'lber: please rf:ltUl'n th'- (orm.anli the patienfs Release aflnforma~on to: 

Medloal Olreola( 

Heal\h Servloes Divlsion 

Waehmgton State Department of Corrections 

PO B0>

---------_........_........ 

.. A i ug.13. 2008 12:35PM 

./ . 

Sc'ott L. Havsy, DO, DAAPM 

'\ 7,J) 

".."ot~ . .' 


• ........,. DEPARTMENT O~ CORRECTIONS 

Medicinal Use of MarijuanaVerification 

OF'FENDER I.D. DATA; 

No. 5731 P. 1 


By state statute the Washington State Department of.CorrectiQns is charged with the responsibility to supervise some 

offenders after they ~ave been convicted ora felony. The above named patient is currently unde~ supervision by the 

Department. S'upervision is designed tei help the offender avoid those environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the.court or 

the Department of Corrections will impose a condition of supervision ·that the offender not use, or possess illicit drugs, 

including marijuana, This offender has claimed that they have a condition for which the medicinal use of marijuana has 

been prescribed:The below verification is to determine the legitimacy of their claim. Thank you in adva,nce for your . 

assistance, If you have questions please feel free to personallycontaci the Medical Director of tbe Department at (360) 

725-8700.' . . . . 

1. I.s this patient unQer y.our care ~ DNo 

2. Ale you prescribing medical marijuaha for his, patient due to a diagnosis of Acquired- 

Immunodeficiency Syndrome (AIDS)' . 

3. 

a. If the answer te question 2 is ·Yes·, does he/she ha,ve anorexia 

b. If the answer to question 2a is ·Yes H , d,oes he/she have weight"loss . 

Are you prescribirig medical marijuana for' this patient.due to nausea and vomiting Clssociat!'!c 

. wit~ cancer chemotherapy 

" 

a. If the answer te question 315 "Yes', has the patient faileqto respond. to canventional 

a:ntiemetic treatments'. . . 

DYes 

DYes 

·DYes 

0 Yes 

DYes 

. b. If the answer to question 3a is "Yes·, please describe what these treatments were (medication, dbse, 

dura~on): . . 

--rrNo 

DNo 

DNa 

c. What isthe planned schedule of chemotherapy 

4, V"hUe on community supervision ("parole") the Department' of Correctiens only authorizes the 

use of the oral synthetic formulation of marijuana. If the Deprtment authorizes this pati~nt's 0 Yes -EtrTo 

use .of medical marijuana, will you be prescribing .only the .oral synthetiC formulaticn 

5: . The patient's accompanying Release of hiformation' autharizes yeu ta previde the' ;J, ~. 

Department with current a"nd future inforr:nation related to this issue. Do yell agree te notify OY~ _. 0 No. 

the Department's Medic1 Director .of any changes in you;:,r~. ~w::.:e::!.ts~ab~O~V~e~ _______ ----,;-(t.!...-___ --,-___ _ 

'ticense#: , vf1»()()~ 

Prescriber's Address it], 

Licep.se type: 

·w /ft:# jL U4 C Phone Number '$) r& 3 ~ $ 3

.,' 



P.O. Box 41100· Olympia, Washington 98504-t100 


Dear Mr .••• 

Your Medicinal Use oH/J.arijuana request was received on December 23, 2008. Upon review by the 

Department of Corrections' Health Services physician, Tour request has be~ denied. 

You may appeal this decision by sending your written 'request witbjn 15 business days of thi$ letter, 

which is on or before February 16, ~009. Please send your r~quest to the address below: 

Karen Daniels, Assistant Sec:-retary 

.Community Corrections Division 


P.O. Box 41126 . 

Olympia, WA 98504-1126 


Appeals that do not contain new information will be denied. You will reCeive a r~sponse to your 

appeal request within 30 ~ys ofreceipt~ 

Karen Daniels, AS$istant Secretary 

Cqinmunity Corrections'Division 

KD:md' 

cc: Nanette Degeorgio, Community Corrections Supervisor 

Theresa Engdahl, Community Corrections Officer 

Field File 

Physician'S .Office: 


CBRMedical 


Spokane,. W A 99202 

". Working Together for SAFE Communities" 

PDU-6655-3 000185

.Distefano, Monica J. (DOC) 

From: 

Sent: 

To: 

Subjec~: 

Hammond, G: Steven (DOC) 

Thursday, January 08, 2009 1 :22 PM 

• D.a.ni.el.s'ilK.a.re.n.R •.• (.D.O.C); Distefano, Monica J. (DOC) 

MM Request 

Mr. _reque:st.for medical marijuana use does not meet medical neccessity criteria. 


Chief Medical Officer . 


Department of Corrections· 

POB 41123 

Tumwater, WA 98504-1123 . 

360-725-8700 

.1 

- PDU-6655-3 000186

I 

1 

I 

CBK Medical lnc, 

No, 2825 p, 1133 

I Fax: 

CBR MedIcal, Inc 

q115 E. MisslOh AVe 


From: mehQSfA.~@ C Be 

,---.... ........... ~:......:::d...::..~~~~r",.---=D:::at:::G~ '/,; ;orp:{\L,_~_ 

Pages: 

, 

! ' 

Cl Urgent o For Rev(ow o Please Comment 0 Please Reply r:IPlease Recycle 

, -Comments; 

'-~--'. --.-- 

CI3R Medical, Inc.· 3115 F., Mission Avs, Spokane, We 99202 ' ," '. 

Seat\le Phone 206w774-6493 Fax 20B-41M659 Spokane Phone 509-:-242.-862.4 Fax 509-340-271Q 

Tri.CiCes Phone 5094 '\ 6~2267 Fax 5D9-~4Q-2710 Vancouver Phone 3130-635-6464 raJ( 206-418-6650 

CONFlOENT1Alr;-y NOTICE: "This communicatioh is intended , for \he sole use of the individual and 

entity to whom it is addressed, and may contaIn infonnation that is privileged, or confidential and 

exempt from disclcsLlre under applIcable law. You are hereby notified that any dissaminatlon. 

distribution, or duplication of this comf.l1unicatlon by someone other than the intended addressee or its 

designated agent \q striGtly prohipited. 

All Information is Protected Ul1d$r U.s, Federal Law 

PDU-6655-3 000187

~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal lnc. No. 2829 P. 2133 

/"'.... . oI'fENDJ:R ~tl.ll' .. rA! 

(~ STATE OflWASHINGTON 

. ~ DEPARTMENT 01' CORREC1'lOI\l$ 


hereby authorize the· use or disclosure of my health Information 

as described below. The following individual or organization Is authorized to malce the disclosure; . 

Nf\ME: C 8 K j.{e.A i c., (L/ b Co " 

ADDRESs.: .'-2' I I "":r t"-- , A/Ir' 50 -:;" cJ ' . 

ADDRESS:;Y' ~r ~jZ;eX 'ft5jtJ Y1 

! understand that I have a right to revoke this authorization at any time. I understand that if I revoke this . 

authorization! must do so in writing and present my written revoGation to the Health Information M

Dec. 23. 2008 5: 06PM CBRMedical Inc. No. 2825 P; 3/33 

Ol-l-cNUcK W. MIA' 

To be·filled out by Prescriber: 



offenders after they have beEm. convicte.d of a felony. The above named patient is currently under supervision by the 

. Department. Supervision is designed tt) tlelp the offender avoid those' environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality •. Accordingly it's usual thafthe court or 

the Department of Corrections will impose a condition of supervision fhat the offender not use, or possess illicit drugs, 


been recommended. The below verjfication is to determine the legitimacy of their claim. Thank you in advance for your 


725-8700. .' ./' . 

1. Is this patient under y~ur care . D~ D No 

2. Ate. you recommending medical marijuana for his patient due to a diagnosis of Acquired 


a. If the answer to qllestion 2 is "Yes", does he/she have anorexia 

b. If the answer to question 2.a is ·Yes·, does he/she have weight loss 

3. Are you recommending medical marijuana for this patient due to nau~ea and vomiting 

associated Wlth cancer chemotherapy . . '. ). 

4. 

a. If the answer to question 3 is "Yes·, has the patient failed to respond to conventional 


DYes 

r 

~. 

~ ....... t:l"ND 

G}¥ee-~ 

DYes 

Q~~ 

Q¥es---fj No 

b. If the answer to question3a is ''Yes'', please describe what those tr~atments were (medicatiori, dose, 

duration): . . tv) ~ 

c. 

a. 

What is the planned sChequle of ChemotherailAf! 

.. ~ 

·If you answered "No' to items 2 & ~3. above, what is tt)e reason you are recommen .' 9 medicinal use of . 

marijuana . f2.. •.:j..... t.l..!t" ~. ..l.) \ ."' \... '-)-J.... J.I1 

. J t \).v>'·f. 

/1 {'. I rf-~";I '.)r~. ."..., ",. r ".. 

. .'/ . ( ,I 0.')'·' 

I I ~ l J . 

Please provide evidence published ih.a peeHelJiewed SCientific publication t support the medicinal use of . '-4!,.,F 

marijuana for this purpose . /,t') ./ .... J'. 

~! C~. :.: ... ...,.~.,1..,

Dec.23. 2008 5:07PM ,CBR Medical Inc. 

No. 2825 

P. '4/33 

--presenber's NllnlG (Print) 

License#: 

Prescriber's Address

j 

I 

i 

I 

I 

·Dec.23. 2008 5: 07PM CBR Medical Inc. No. 2825 P. 5/33 

Document"ation of Medical Authorization to Possess Marijuana 


PATIENT NAME: __ _ DATE OF BIRT!-I: _982 . 

I, Antoine John§..9.!L. I am a physici·an licensed in the State ofWashingtbn 

and I am treating the above patient for a tenninal iII!'1~:or a debilitating condltio'n as defined by 

RCW 69~51A.010_ " • ,! 

I have advised the above named patient abq~l(the pot¢ntial risks and benefits of the medical use 

of marijuana. ! have assessed the above named pati\int's medical history and medical Gondition_ 

It is my medical opinion that the potemiii\r"benefits of.jhe medical use of marijuana may outweigh 

the health risks for this patient. ,:/ . ..:/ . . 

Physician Name: _----'D::.;r"-.-~A.:..::nt:.;;o.;:.;in'El~,J=oh=n.:..:;s.;:;.on:.!.__ _'__WA License NUrriber:. ___ M_D_O_OO_3_9_0_48- 

Date: __..:..1.:.:.1/.::..:02!=2::.:0::.::0~8___ 

.. 

Risks al7d benefits of medical marijuana / 

Under Washington law, the use of edi¢al marijuana Is' now permissible 'for some patients 

with terminal or·debilitating illn~sses_jTh~/law regulating this (RCW a9.51A) allows physicians' 

to advise patients about the risks an9 be(iefits of the medical Lise of marijuana_ 

The medIcal and scientific evide~[;e ;;'upporting the use of medical marijuana remains 

controversial in the medical commupity/ Not an health care providers believe that medical 

marijuana is safe or effective and s9m~ providers feel that it is a dangerous drug_ . 

According to the Washington St*tgl8W the benefits of medical marijuana may include 

treating nausea and vomiting from ~emotherapYI AIDS wasting syndrome, severe muscle 

spasms frqm multiple sclerosis or o'-Lher spasticity disorders, glaucoma, and some types of 


Some of the risks .of medical marijuana may include possible long-term eIfects of the brain in 

the areas of memory, coordination and cognition; impairm(mt of the ability to drive or operate 

heavy machinery; respiratory damage: possible lung cancer; and physical or psychological 

dependence. 


As this patient's "60 Day Supply", as stipulated by RCW 69_51A.040 (3)(b) and 

WAC 246-/5-010, this Qualifying Patient can reasonably expect to have in 1heir Posession and 

-------'I'iJ~efd-ailjtalof·J1bliTore-tharr2"4-e)tmces-of"l:I·seable-Marijrrarrct'-cmd-no-rnore-than-1-5-Plants:-. ------- 



3115 E_ Mission Ave, Spokane, WA 99202 

Spokane: 509"242-8624 Fax:509-340-2710 

Seattle: 206-774--6493 Fax: 206--118-66Q9 . 


CALL 509-570-2886 OR 509-570-6943 

PDU-6655-3 000191



P.O. Box 411 00 • Olympia, Washington98504-11 00 

April 29, 2009 

Mr ...... 

(/0 ceo Jon tS 

DearMr_ . 

Your Medicinal Use of Marijuana request.was received on April 20, 2009. Upon review by the 


. .. 

You may appeal tbis decision by sending your written request within 15 business days cjf receiving 

this letter. Please send your request to the address below: . 




P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional infonnation that was not included with your original request. 

Appeals that do not contain new infonnation will be denied. You will receive a response to your 

appeal request within 30 days of receipt . 

Sincere1Yj 

. / ~ 

(j.~". :;b ft./-_/:., 

.,. ,......::-;,... ~ 

Karen Daniels, Assistant Secretary . 


KD:md 

-----,cc:....-.-Geot:geJones,-Communit)LCoJ.:tections-O'ffice.r,~----...:......-------------- 

Marjorie Owens, Interstate Compact Unit . 

. Field File-_ 

. Physician's Office: 

Dr. Thomas Orvald 

1813 l30 th Ave. NE #210 

Bellevue, W A 98005 


-0 recycled paper 

PDU-6655-3 000192


From:, 

Sent: 

'To: 

Cc: 

Subject: 

, Johnson, Deborah A. (DOC) on behalf of Hammond, G. Steven (DOC) 

Monday, April 27, 2009 2:38 PM , 

Distefano, Monica J. (DOC); Daniels, ,Karen R. (DOC) 

~C), 

~MRequest 

for authorization for use of medical marijuana does not m'eet criteria for medical necessity. 

4 

PDU-6655-3 000193

THCF.MedlcaI ·Clinics· 

'"9,-J, . 1~1313Qth' Av~ N~E. #210 

. ~ ,.' . . Be~evue, WA Q8005 

r~.:.~l 

lA~\.I"'" '. Phone: 425-869-6186 or 1-S0~723-0188. 

. ., '1~'0~" FaX: 425:-869-6378 . 

. '\ \ .... 

~'f(~. ;S{:.f·. www .• thc-fountJIation.or:: or www.hemp.org 

;~D/BUSfNES8 SVCS 

, 

l 

1". OF CORRECTIONS 

.~. . 

. . ct'·'i\·- .' .•. 

. ' ... \\~S\~~Documentation ofMe9icalA1;lthorization to Possess Marijuana for Medical 

.•

FAX No. 509-921-2346 P. 003 

r-.... 

(~ STAT&:OFWASHINGTON 

DEPARTMENT OF CORREC110NS 

I.JU!,# 

Medicinal USQ of Marijuana Verification. 

To befiJled out by ceo: 

I Patient'~ Name _L-... 

OFFSIIIl51l.1.D. QhT", 

__--:-__--,-_--J_==:..1_ 8 9_ 

l o/'_5 ____ 

I ,...-LI__ 

er ___... I· 

To bllfmed out by Prescriber: I . 


By state statute the Washington Slate Department of CorrectIons r~ charged wlth the responslbiiity· to supervise some 

offenderS after they have been convicted of a felony. The above named patient is currently undl'lr supervision by the 

Department. SupervIsion is designed to.help the affender avoId lhQIOe environments or slttJatio!'l$ that lead to their criminal 

behavior. Often illicit drug use Is !i contrlbutingfacto( in an indivldua.l·s criminality .. Accordingly Itls usual that the court or 

the Department of Corrections will impose 8 condmon of supervision that the offender not use, or possess ilficit drugs, 

Including marijuana. This affencjer has claimed ~hat they have a condition for which' the medicinal usa of marijuana has 

been recommended. The belollv verification Is to determine !he legitimacy of their claim. Thank you In advance for your· 

assistance. Jf you have questions, please contact the CommunIty Corrections Aasistan~.Secr.etary at (360) 7'2.5-4!.787. 

1. II'! thIs patient under your c~re7 Q'Yes 0 No 

2. Are you recommending medical marijuana for this patienl due to s dlagnosfs of Acquired 


a. If the answer to question 218 "Yes','does he/she have anorexia, 

b. . If the answer to questIon 2a is ·Yas", does ~e/she have weight Joss' 

DYes 

DYes 

DVes 

~o 

DNa 

ONo 

a. Are you reoommending medical marijuana for Ihls paDent due to nausea and vomitlng 

. assoeiated WIth cancer. chemotherapy 

a. Jf the answer to quesfion 3 is "Yes', has the patient failed to respond to conventlol'lSl 

entlemofic ireatml)nts 

DYes 

DYes 

b. If the answer to que3tJon Sa is "Yes", please ctesetibe whISt those treatments were (medication. dose, 

du~tion): .. .. . . . 

0No' 

ONo 

c; Wh

., 

FAX No. 509-921-2346 

P.' 004 

Pr~criber's Address 

Phone Number 

Prescriber: please return thl~ fom and the patient'e Release of Information to: 

Medical Drreator 

Health Servioss Division 

Washington StaTe Departmeniof Correctlone 

ceis9x·411W 

Olympia, WA9B604-2113 

pnyolclcm's Nema (F'rtnt) 

Physr;ran's Slgnawre 

Instrllctions to DOC PhysiCian: 

When form is colnplete: 

i. Email your finding above to the Assistant Secretary tor Community Correct/ons. 

2. FJls this form and tha accompanying Release of Information in Liberty as a Community Correctlcns Health Record. 

8~e f~ (RCIiIJ 70.Q2; RCW1Q.24.'05i RC'/{T1.0S.S90) ancllor fedenl T"9ulatlohSl (42 CFR Part 2; 4S CPR PISrt 164) prohibit 

.diIiClOl5un: oftms InfcmnatJon withom the spegilic wrjtf;en consent of rna Jl&Tson to whOfll It partalns, or as othe('Wlso 

PQnnltted by taw. 

DOC 14-053 (Rev.3i16{09) 

OOC3BO,200 

PDU-6655-3 000196


DEPARTMENT OF CORRECTIONS· 

P.O. Box 41100· Olympia, Washington 98504-1100 

April 29, 2009 

Dr. Olympia. Tachopoulou 

Northwest Medical Specialties 

1624 South I Street #305 

Tacoma, wA 98405 

Dear Dr. Tachpoulou: 

~erwork you sent regarding the Medicinal Use of Marijuana request . 

_was received o~, 2009. Upon review by the Department of 

Services physician, Mr._request)1as been denied. 

. You may appeal this decision by sending your written request within 15 business days of receiving 

tbis'letter. Please send your request to the address below: . 




P.O. Box 41126 

Olympia, WA 98504-1126 

Your request~ust provide additional inforinationthat was not included with your original request. . 


appeal request 'within 30 days of receipt. 

. Karen Daniels, Assistant Secretary . 

. ·--··-·-,-·eommunity-CorrectionS'·f>ivisiorr·--·---~----·-"·------:-.----.. - .... -----.-.-------.,--- .. - .. --.--' .. -.. ------------ 

KD:md 

cc: Kevin Jones;' CommumtyCorrections Supervisor. 

Joann Wiest, Community Corrections Officer 

Field File -_ 

" W

..' ...... M" ••••••••••••• _ •••••• _ ...... " • 

... 

A.PR/2t"1'2009/TUE 11: 03 AM DOC OLYMPIA CENTRAL 'FAX No. 360-586-0983 

v"=-', .... .." ~V ... ~ ~'U. ":t.~ .&..,~ ~..,~ 

",rr 1rI4-~""~CIo"" ......... c.'-'.a.~ .... "' ... 1:.oa 

l 

~ 

. '._-'.' 

P; 003 

NWMS 

NORTHWEST M~DIC:AI. . 

5PIiiCIA1.TJES, PI.LC: 

Infed/ons Umlted. P.S. 

H,matol09)P Ontology Northw.st.P.C. 

~iniar Physicians, Poe. 

Cl T.Jca~1. 0ffl'1t: 1624 s~ I Street 1130S. Tacoma. WA 984aS (253)428·8700 

o !!..! .... I Way Offica: 345Q9 9th Ave.S. #1 07, Federal Way, INA 98003 (253) 95:1:-8349 

Cl Lalaswood Office: ·113118rldgflpottWay SW 11304, Lakewood, WA !/849S1 (253) 983-1377 

o Puyallup Office: 220 l~h Alle.SI; #8,. puyallup. WA 98372 (253) B45-8991 

o Rainie.Office: 400 151h Ave.S~, P~lIup,WA 98372 (2S3} 841-4296 

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION 

___ -.... __ DateofBirt:h.: 

SSN: 

Previous Name:_---' __________ _ 

to ri:lcase health .:are 

Zip Coe:!e: Of gso '1-J= I I '3 

RECElVEO 

';[his' request ~ authorization applies to: . 

~ Health 'c;u:e information rebtin$ to rhe following tr~tment. c:onditio~, or dates of treatment:- 

APR '222009 

Dept ot Corrections 

Heaith Services 

~ N1 ht$th =einformation ' 

~Om~~-__________ ~------------~----~------------ 

I understand ~t my exp~ess consent is requ:ircdto release ~y health care information reh1cing to testing. diagnosis, and/ 

. . - 

or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiac:ic disotder:>/rn~IU:al he:l1.th, and drug ane:!! or 

~:kohol use. If r h:l.ve been res tee:!. diagnosed.' or treat~d for HIV (AIDS virus). sexually transmitter;!. discasc6, psychiatric 

disorders! mental health, or drug and! or alcohol use, you a1'e specifically authorized. to-release all. health care information 

:relating to such diagnosis, t:estiJ:i.g. or tre.annent. 

Signature of pa.tient or patiel1t's autboru;ed representative 

Date. signed. 

Relationship or st:atus if signed by anyone ocher th:m p.:tic:nt. (parent, lc:g:!l guardian. penlon.u .represent:l.tive, etc.) 

THIS AUTHORIZATION EXPIRES 90 DAYS AFTER THE DATE IT IS SIGNED 

MR·201 

Rev.2J2007 

PDU-6655-3000198

,ttors,4 


i! IJf.P'J f DEPARTMENT OF CORRECTIONS 



. To be filled out by ceo: 

I ~atient's Nam_'-'-----J....'-DMrw"-'-'-. __.-l' iiiiI8LJ 


Dear Pr!;lscriber, . 


offenders after they have been convicted of afelony. The above named patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead to the,ir criminal 

" behavior. Often illicit drug use is a contributing factor in an individual'! criminality. Accordingly it's usual that the court or 




assistance. If you have questions, please contact the Community Corrections Assistant Secretary at (360) 725-8187. 

(~. . r 

... J. Is this patient under your care fJ Yes D No 

2. Are YOlJ recommending medical marijuana for this patient due to a diagnosis of Acquired 


a. . If the answer to question 2 is "Yes", does he/she have anorexia 


~es 

I2(Yes 

DYes, 

D Nc;> 

DNo 

QNo 

3. ' Are you recommending medical marijuana for this patient due to nausea and vomiting 


DYes 

a. If the answer to question 3 is ·Yes", has the patient failed to respond to conventional 

DYes 


' 


duration): 

EtNo 

~No 

() c. What is the planned schedule of chemotherapy 

I 

! , 

4. If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use qf 

marijuana 

a. Please provide evidence published in a peer-reviewed scientific publication 'to support the medicinal use of 

marijuana for this purpose. 

5. The patient's accompanying Release of Information authorizes you to provide the ' 

'-----IJepartmentwith-correntandiotore-information-reiated-to-thiS-isscrg,-Do-yocragree-to-notifY'-~--;;:=------ 

the Department's Medical Director of any changes in your answers above ' Yes Gl No 

D0014-053 (Rev. 3/16/09) IJOO 380.200 

PDU-6655-3 000199

.. 

" , 

Prescriber's Name (Print) Date . 

License #: License type: ·.....;...fvLD_· ______...,--______ 

Prescriber: please return this form and the patientis Release of Information to: 

Medical Director. 


Washington Stat!"! Department of Corrections 

POBo:,.~11;23. . 

Olympia, WA 98504-2113 


()have reviewed this verification form ~hd that u'se of medical marijuana by this patient 

(check one) lOis !Za IS not , 

consistent with DOC Policy. ~ .' 

.71 nSF 'Il_ . ~~ 

Physician's Name (Print) Physician's Signature Date 



1. Email your finding above to the Assistant Secretary for Community Corrections. 

2. File this form and the accompanying Release of Information in Liberty as a Coinmunity Corrections Health Record. 

(OJ 

.-:: _ 

..•........ _ ... ,-_.:'. __ ... ~ 

-"-', ........ " ... _,- .......... -.--- 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) and/or federa( regulatIons (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise 


' 


PDU-6655-3000200

· Distefano, Monica J. (DOC) 

From: 

Sent: 

To: 

Cc: 

Subject: 

Johnson, Deborah A. (DOC) on behalf of Hammond, G. Steven (DOC) 

Wednesday, April 29, 200910:42 AM 

Distefano, Monica J. (DOC); Daniels, Karen R. (DOC) 

~DOC) 

~MMRequest 

for authorization for use of medical marijuana do'e~ not meet criteria for medical necessity .. 

3 

PDU-6655-3 000201


DEPARTMENT-OF CORRECTIONS 

P.O. Sox 41100' Olympia, Washington 98504-1100 . 

April 29, 2009 

Mr._ 

Dear 

Your Medicinal Use of Marijuana request"was received on April 15, 2009. Upon review by the 


i 

I 

I i 

! 

I 

, 

You may appeal this decision by sending your written request within 15 business days of receiving 

this letter. Please send your request to the address below: 



Depar4nent of Corrections 

P.O. Box 41126 

Olympia, WA 9850~1l26 

Your request must provide additional information that was not included, with your original request. 

Appeals tlliit do not contain new information will be denied. You will receive a response to your 

appeal request within 30 days of receipt. . 

Sincerely, 


CommunitY Corre~tions Division 

--------KB:md--------------------------------------------------------------~--------- 

cc: 

Sandy Heurion, Community Corrections Supervisor 

Casie f....rceneaux, Community Corrections Officer 

·Field File -_ 


Dr. 'Thorn'as Orvald 

1813 l30 th A.ve. NE #210 

Bellevue, WA 98005 

. 3< 

txl recycled paper 

" Working. Together for SAFE Communities" 

PDU-6655-3 000202


From: 

Sent: 

.To: 

Cc: 

Subject: 


Monday, April 20, 2009 9:52 AM 

Distefano, Monica J.(DOC); Daniels, Karen R. (DOC) 

... 11..... - -. (DOC) 

MM Request 

_request for authorization for use of medical marijuana does not meet criteri~.for medical necessity. 

" 

5 

PDU-6655-3 000203

. 

I 

I 

04/15/2009 18: 28 4258595378 THCF PAGE 03/04 

/.'."101, . 

f~ STAT'" OIOWASHINGTON . 

I.JIr.x, . OISPARTMENT OF CORRECTIONS . . 

Medicinal Use of MariJuana. Verificatj~n' 

O!'TA: 

To be filled oU~. . 

ratient's Name_'--·-----,------'II....· D_a_te_O_f....:.B_irt-

04/15/2009 18:28 ~258696378 THCF PAGE 04/~4 

. Prescriber's Name (Print) Cate 

b 

" . I t r W\Co'\"''i ~ .. 

License#:,{'i'V'.. . S< li\C~\~:'rY( 0-1~t'L~ LlcEi.nsetype:. _. ____________ ""-__ 

'Prescriber's Address 

. ...l'S 

15'1') 1'"36;'-" ~(.. IVt. ~ 2.ll> '.' Pho~e ~umber 

.eI.\e....."\~ twA- ·&\govS.. . 

·Presc.rlber: please return 'this 'f~rm ant! the patient's Release:of Information to: 

~edical Director . .' 

Health Services DivisiQn 

Washington State Department of Corrections . 

. ' . . 

PO BoxA1'123 . 

. Olympia, WA 98504-2113 

To' bEiill,ed out by .DOC 'PhY8ician: 

I have fevie~ed this ve~~cati~n'~~ }I'lc(find that use. ~f medicar ma~j~ana by this. patient '. 

".'1.. 

'(¢hecl< one) lOis 'lkd'1s oot'. 

lit,.· 

.' consistent with DOC Policy. '. '. J! 11_. . . 

Physiclarr.s·Name (Print) 

~~ 


.' 

Oate 

Instr.uctlons·to D.OC P~ysician: 

When form. is ~cniplete: . . . 

1. Email your finding above to the Assistant Secretary for .community Corrections. . . . 

2. 'File'this:fo~m and the acco.!'TlpanYing·Releas~ of I~fonnaticin in.Lib~rty as a Community Corrections Health Record. 

'State law (Rc:W70.D2i RCN 70.24.105; RCWj1.05:390) and/or federal regulatit;ms (42 Ci'R. Part 2j 45 CF.R Part"164) .prohlblt 

'disclosure ofthls infonnirtion wit~out·th9 specific written conss\'It of the person to whom It per1alns, or. as otherwise. 

pormllt=d by law. . . . 

DOC 14-05~ .(Rev. 3/16f09) DOC 380.200 

'. 

PDU-6655-3 000205

04/15/2009 18:28 4258696378 THCF 

PAGE 01/04 

Fax Cover Sheet 

THCF Medical Clinic 

Thomas Orvald, M.D. 

1813 130 fu Avenue NE, Suite 210 

Bellevue~ WA 98005, 

Phone: (425) 869-6186 Fax: (425) 869-6378 

I 

I , 

! 

'From: 

() {' t--- 

Attention:, 

--~--~-------- 

Phone: _____________ ~ 

Phone: ________ __ 

Fax: _~_.......:..---___:_-.....o.--- Pages:' "S '+ (oj-v" 

~e: SI' 'l ' i \- l../",,") 

P (e~s~ c.C-il\ 'I~ ~ 

" 

. . 

Notes: 

~ 

.~ 

'- 

PDU-6655-3 000206

04/15/2009 18:28 4258696378 THCF PAGE 02/04 

.: 

STA!E OF WASMINGTON 

. DEPARTMENT OF CORR.ECTIONS 

D. eo~41126' Ol).mpis, Washington 98504-1126' (360) 725-8196 

• Ff'X (SeO) 586-0252 . 

March 19,2009 

TO: 

Community COIT6cODS Divisi~ 

'SUBJECT: 

. ....1) .. }.. ~ 

- ... ~ .. 

. Karen Damcls, AsSl~t Seeretaxy . 

Medical Marijuana PJ:'ocess Change 

. . ." . 

E:£f~~ve ~e4iat61y, DOC Form. 14-053, ~edicina1 Use ofMarijuan.aV:eri£i~tfcn, has been upds±ed .. 

. . . 

. Offenders will no longer be required to .fill.9ut tbi$ f9nl\ when they ha\,"e a legitimate prescription for. 

Marinol from a licensed physician. In additiop, offenders that have·~s.prescription will nol be in· 

.~ollition. iftb.ey test positive for THe. " . . 

The Department created a verification process' for offeri.d.ers to obtain approyal for the use of "medical 

.marijuana.". If an. offender tells his Or her ceo that they plan on using me~ca1 marijuana., Foxm 14-053 

should be provided to the offendet and the ],rocess e"-'P1ai'Oeci As a reminder. here.is.the·brealcdown of 

the approval proceS!: . . '. ' .. '. 

1. . Upon receipt ofFo~ .14-053, thl:) offender and bis or her medice:l provid~ ha,ve.2 weeks to 

~o:tnp'lete and subnnt it to the DOC Headquarters Physician for review. Once the Physician 

receives. the fOrn1,..he will review it an,d make his determination Within 10 days; upon wbich. time 

. my. 'offioe will comml,lllicate that decision in writing to the offender'vvith a copy to the eco~' 

.. the CCS, and the ~edical provider. 

2. The offender and the medical provider will then have 1'5 ·;SUSrNES.S 'days (3 weeks) to submit a 

'written app.eal d1rectly to·me. Once I receive the appeal, a deciSion will be· made within 30 

business. days. That deoision will s.gaUi. be ccnnmunicated ili writing to the ceo, the ees, and 

the medi~ provider. 

Please remember that the offender should l;llJtTe~eive any vIolations related to the use ofm~dicina1 . 

------_msrijuana.dm:ing..this_pIocess_period.-E1ease_d.o...no_t.hesi:tate_to_ca11:mejf..Y..o_u.hay!ulIly_o~r...qy,~~~~: ___ .~_-:-__ 

Tha:Dkyou.· . 

KD:~d 

.00: Eldon VaiL Secretary 

Cheryl Strange, Dcp:uty S.;cretary . 

Scott Blonien, A,ssistant Secretary .. n;,.!>




April 29, 2009 

Mr." 

Dear 

Your Medicinal Use of Marijuana request was rece:ived on April 27, 2009. Upon review by the 

Department Cf Corrections' Health Services physician, your request,has been 'denied. 

You may appeal this decision by sending your written, request within 15 business days of receiving 


' 

Karen Dani~ls, Assistant Secretary 

Community Corrections Division, 

, Department of Corrections 

P.O. Box 41126 

Olympia, wA 98504-1126 . 




Sincerely; 

Karen"Daniels, Assistant Secretary 

Co~unity Corrections Division' 

-------KB:md~~------------------------------------------------------------------ 

cc: . Jack Hills, Cornm1,lnity Corrections Supervisor 

Juliann MC.B.n.· d.e., C.ommunity Corrections Officer 

. Field File "'II 


. Dr. Thomas Orvald 

1813 130 th Ave. N'E #210 


" Working Tog~t'7er for SAFE Communities" 

PDU-6655-3 000208


From: 

Sent: 

To: 

Cc: 

Subject: 


Wednesday, April 29, 2009 ·10:45 AM 

Distefano, Monica J. (DOC); Daniels; Karen R. (DOC) 

~~ 

~MRequest 

for authorization for·use of medical marijuana does not meet criteria for medical necessity. 

1 

PDU-6655-3 000209

Fax 36027706511· Apr 20 2009 04;31pm P002/003 

':1 

OFJ'ENCER I.C. CATA: 

'"~"""'~"'"'lE"iVED 

" .".• ~' !... ~. 5 . 

APR L 72009' 

STATe OF WASHINGTON 

DEPARTMENT OF COR~eCTION$ 


Dept of Corrections Health Services 

. ~ .. r 

TObefl ......... ~~ .. 

·1 Patient' ~~\~ ) 1.,.....,Io=:..=5:"=------1...I_ 


D0iIIIi=J 



offenders after they have been convicted of a felony. The above named patient is cutrently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or sitUations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality, Accordingly ifs usual that the court or 

the Depoartment of Corrections will impose a condition of supervision tha.t the offender not use, or possess illicit drugs, 

inCluding marijuana. This offender has claimed tha.t they have a condition for which the medicirial use of marijuana has 

. been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your. 

assistance. If you have questioAs, please contact. the Community Corrections ASSistant Secretary at (360) 725-8787. 

1. Is this patient under "your care 

Bfes 

DNo 

.2. Are you recommending medical marijuana for this pa.tient due to til diagnosis of Acquired 


a. If the answer to question 21s "Yes", does he/she have anorexia 

b. If.the answer to question 2a Is "Yes", does. he/she have weight loss 

DYes 

DYes 

DYes 

B'No 

DNo 

DNa 

3, Are you recommending medical marijuana ,for this pa.tlent due to nausea and vomiting 


DYes 

a. If the answer to q'uestion 31s ·Yes", has the patient failed to respond to conventlonal 

DYes 


b. If the answer to question 3a is "Yes·, please describe what those treatments were (medication, dose, 

duration): 

[g-Mo 

DNo 


4. If you answered "No· to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana . 

. C. Jt\{Cd\(t.. rr'"" 

a. Please provide evidence published in a peer-reviewed scientific p~blication to support the medicinal use of 

marijuana for this purpose. 


Department with current and future information related to this issue. Db you agree to notify D'Yes rt_.....r.: 0 

. the Departm enrs Medical Director of any ohaog~Jo-y.o.ur:..ans.wer.s_ab.o.v.e.t-.--_---,--==--.:.~--""b!:::C!.~=-----,:--- 

DOC 14-053 (~ev. 3f1 p/Oe) 000380.200 

PDU-6655-3 000210

Fax 360217065t! Apr 20 2009 ot!; 31 pm P003/003 

,PresCriber's Name (Print) Prescribe(\s Signature Date. 

License #: lY\ 1) . 000 I b 1'lS D License type: 

~r'\"'V\ Sc. t,,r€.c::. ic;'-"c;I( ",,f...f.fc.:c .. 'VV\"IfII'"'::7'.(/ , 

Prescriber's Address (91) I)G " ... 4"" tVC.l-lfiLo ' Phone Number c.(Z~ -t'(q-6,\




April 29, 2009 

Mr." 

Dear 

Your Medicinal Use of Marijuana request wa:s" received on March 30, 2009. Upon review by the 

Department of Corrections'. H~alth Services physician, your request has been denied. . 

You may appeal this decision by sending your written request within 15 business days of receiving 





P.O. Box 41126 

. Olympia, WA 98504-1126 




Sincerel" } 

Karen·Daniels, Assistant Secretary 


--------KB:md----------~---------------------------------------------------------- 

cc: KUrtis Smith, Community Corrections Supervisor 

Sean Tuitele, Community Corrections Officer 

Field File-_ 


Scott 1. Havsy, DO, DAAPM 

3716 Pacific Ave., Ste. E 

Tacoma, WA 98418 . 

. " Working Together for SAFE CommunWes u 

\ ~ ,,,,,ycl,d I"'PC' 

PDU-6655-3000212


From: 

Sent: 

To: 

Cc: 

Subject: 

Johnson~ Deborah A. (DOC) on behalf of Hammond, G. Steven (DOC) 

Tuesday, March 31, 2009 1 :41 PM 


Hammond G. Steven (DOC) 

MM Request 

E:ric Unger's request for authorization for use of medical marijuana does not meet criteria for medical necessity. 

8 

PDU-6655-3000213

I ' , 

..... 

MARI3DI2009/MON . 09:30 AM 

FAX No. 

P.OOI 

FAX COVER SHEET' 

, STATE OF WASH,INGTON 


9L YMPIA F,IELD OFFICE #364 

'& O~YMPIAMETRO #386. 

3700 Martin WaYj Suite #104. PO Box 41121 

Olympia, WA 98504-1121 ~ (360) 459-6370 

. 'FAX (360) 407-~075 

Date:' .3!)o>/o' 

, To: --,t-,&~....:..;:/C.~If_---(".o:O:....;..'1,""V2-=:;".t,-,-!4-,-~_o _____ -:.. -# of Pages: -,-Y_' ___ _ 

,Office: ________ ~ _ _'_ 

I 

i 

I 

. Unit #364, Olympi,a: - U,nit #386, Olympia Me,tro: 

D CCS' Kurt Sm"lti," 

... -, 

'0" 

ees Rochelle HUQhe:s 

o ceo Patrick Austin, 0' ceo John Chinn D ceo Andy Scroggs 

o ceO"Sa~ha Brooks D C~o Fred Wiggins :D ceo Michael Fost~r 

0' ceo Jose Cortez , 0 ceo Gre,9 Young.(~76) D CCO 'John Jackson 

, .' 

D ,ceo Mati Frank D S8 Sue Rit,ter [j ceo Brandi Murphy 

, , ' 

D ceo. Jim I~on 

ceo Kristin Wiss[~r 

~ ceo S'ean 'Tuite!e 

o ceo Greg'Tuit~le 

D OASMari~ Anderson 

D GAs Sonya Ford' 

, " 

D 

0 . OAS Jessi Herrin 

o Civ.,iGenics: Mike Inlold' 

COMMENTS: 

___________ ~-~------~--_..,_-------~020aoa5r 

I 

I 

, CONFIDENTIALITY NOTIce , 

This facsimile transmission. and anY,documents accompanylns it,'may'contain confidential information belonging to the 

sender. and, which may in, p~rt or whole, be protected by Title 18, Unites States Code,' Section 3153 and Pretrial 

Confidentiality Regulatlons. Thi,s information is intended solely for the use of tlle individual or entity names above. If you 

are not the intended recIpient you are hereby notIfied that any disc;:losure, copying. distribution, or tne taklng of actIon 

upon the contents of this information is prohibited: If you have received this transmission In error, please notify our office 

immediately by Ihone to arrange for the retum of the, documents transmitted. Thank you for .your cooperation. 

PDU-6655-3000214

MAR/30/2009/MON 09:30 AM FAX No. P. 002 

• ·Mar. 17. 2009 2:41PM Sco! t l. Havsy, OO,DAAPM No; 1144 P. 1/3~l(-~n ... 

r~~:~'~ -, 

TO: 125347305'45 

~t STJoTlilOFWASHIIIGTCH 

...., DEJ'AR'lM!NT OF 'CC'fm;CTlONS' 

Madlclna' Use' of M4rijua~a VerificatIon 

o..r Pr$$OfIber, .'. . .'. • 

By 5tars lilah.rbJ ifle Washlngton ·State-~ent·of Correctrons is ~d' with the respol1llbllTty Ie aUpeMsft some . 

• ~~[1 SIler t1Iey haye been convIded of a felany. ~ ~ nmnsd pallen( III currently und!r $Uperv"lSiOt'I by ~ . 

oep~ent Sl.lpervllllon til .de!t~d to help th~ o1f&nder zvokl thelll ~nvtronmen1l! or sltUS.UO,.. tI\~t lead to tJ1eJr criminal 

bohlWlo!'· Often Illicit-drug ul!6i:!l.a col'lictbullng fatter In an individual'. aimlmllity. Accordingly ~'. usual tltllt tho C01.In or 

till Depattr!l8lll or Correclions wflIlmpcse I eol'!dl!!c~ of 8up.rvtslOR !hat the offMdar not 'Use, wllCUvn IlJk;It d~, 

lnd'udlng rnarflU!3J'l8. . This offender tla claimed that they hay. II concloon fcrwhich Ihl! mediclnaIl U$e ofmarijtrans'nas 

~"" rlQ;1mm';l'Idod. Tho tlillQW ve!'iflcatiQn "to determine the leg'lllmacy of iIleir clarm. /hank.)'tIu In advanca for your 

.'Illianes. 1f)'OI.I nave questions pleae feal free' '" panrollZllly ~nlJlC'lIhe Medtcal Director at' the 'C)eparfmentat (360) 

·"~:!~~~·r;.iti.n;·~nd'j:yo~·-~re7·"·"""··"··"·· ........ .... i .• :-....................................... -~ :·-lj:JN~· ........ :: ................. .. 

2. Are you l'GCommel)/IIns medical marijuana fer hi~ pali~t ~ to I dll1Sl'losls of .Acquired 

Immunodeflcfeney S~dmme (AIDS) . • • 

'8. I1the snswer.lo qtle~ 2 is "Yes", does he/s~ have anoraxia . 

D. If lhG anS't\lQr to C!~rion. 2a ii "Ye~·. doe; h$/$~ naYil ~I~ht Ion 

. 3. ke YD\! recommending medical mQl'ljIJana for tI'Ilf pmlent due to.nsusea and wrnlling 

atiaoc::l* ~ft cancarcl'lemalherapy '.. 

iii. If the answarto que&l1on S Is "YtlS", Mathe petlel'll fane

MAR/30/200S/MON OS :·31 AM 

FAX No, P,003 

Mar,'n, 2009 2:42PM Scott L Havsy, DO,OAAPM No, 1144 p, 2/3 

Prei@tiQiJs Nam. (PliI1t). - "if\ii;iiiis;;;;;n;.,er:;;:. sir.i~=:;;-------- 

'UQaJise iF:. .. 1Jf I /Uf,{rf 

P(Ut.riber's Address . 

;r- lfoenn type: 

.. 

Medical Oirecwr 

HHlth S.tvlefli C(vltdan 

WllshtngtQn state Department of CorreetI.onS 

PO BoX41123 

Olymp~, WA ga504-~11"3 

__ ~"';"";' _____ -'---______ SCOIt LH",vsy. D0, OMPIY 

3716 PacificA'Ienue S . ----- 

To "filled out by DeC Phy.siClan: ,Ta~ma, WA 9841a f ulte E 

I have mlswed tills VGr!flcaag(.form and find Iha~ us. Qf medloel ~erUue". by thIs. patl"nt ',...:. ..... 

(~on.)Ia;;r1l o Ie not ~. 

col\sl$tent with DOC F'oIkY. .. 

SCD±\: '~V

MAR/30/2009/MON 09:31 .~ 

Ma r. 17. 2009 2: 42PM 

FAX No, 

Scot t l. Havsy, DO,OAAPM 

p, 004 

No,.1144 p, 313. 

P. 1 

I 

Date/Tim 

Fi Ie 

No. 

Ma h 

4. 200a 

Des! i ~at ion 

8492 Memory TX 13604070075 

Page 

Not Sent 

R.aL.l.dll 11Qi I' IJ'f.1t . 

E. '1 Han. "~ rtf lin. 1 .. 11 

E. S Na en i.".~ r . 

E. IS .; ~ • , • do 4 "":.' 0-(11& 1· 1 • i .. 

E. :Zl 

S.

I. 



P.O. 80x41100' Olympia, Washington 98504-1100 

. April 29, 2009. 

Yakima, W A 98901 

. Dear Mr._ 

Your Medicinal Use of Marijuana request was received on March 25, 2009. Upon review by the 

Department of Gorrections' Health Services physician, your request has been denied. 

You may appeal. this decision by sending your written request within 15 business days of receiving 


. Karen Daniels,' Assistant Secretary 



P.O. Box 41126 

Olympia, WA 98504-1126 . 


. Appeals that do not contain new information willbe denied. You will receive a response to your . 



Cornmunitj Corrections Division 

----.K.D.~mdd..-----------------~-------------__:_---- 

cc: Catherine Lecompte, Community Corrections Supervisor 

Shelley Mesplie, Community CorrectionS Officer 

Field· File -_ 


.. Dr. Thomas Orvald 

THCF Medical Clinics 

1813 l30 th Ave. NE, Ste. 210 


" Working TogetlJer for SAFE Communities" 

o ",cycled p'pcr . 

PDU-6655-3000218


Froin: 

Sent: 

To: 

Cc: 

Subject: 


Friday, March 27, 2009 3:22 F>M . . . 


~) 

____ MM Request 

for authorization for use of medical marijuana does not meet criteria for medical necessity. 

9 

PDU-6655-3000219

MAR/18/200S/WED 03:05 PM 

FAX No, 

MAR 252009 

Dept of Cprrectioras 

Health Servic~s 

To be flJI~ out by Prescriber:, 

Pear Prescriber, ' , 

By state statute the Washington State Department of-Corrections is charged with the responsibility to supervise some 

offenders after they have been 'convicted of a felony. The above named patlent Is currently under supervision by '!he 

Department Supervision Is designed to help the offender avoid thOS& environments or situations that lead to their qriminaJ 

behavior, Often Illicit drug use is a contributing factor in an Individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will Impose a condition of supervision that the offender not use, or possess Illicit drugll, 

Including marijuana Thls 6ffen~er has claimed that they have acOndll1on for Which the mediansl use of marijuana has 

bean recommended. The below verification is 10 determine the legitimacy of their claim. T.!'Jank you In edvaFlc8 for your 

3sslstanee. If you have questions please feel ITeS to per-lonally contact th~ Medlcal Director ofthe DepartmeDt at (360) , 

725-8700. ' 

1. [s thls,patlent under your care 

2. Are you recommending medical mariJu~na for hIs patient dUe to a diagnosis of Acquired 

[mmu!lodeflclency Syndrome (AIDS) 

a. If the answarto question 215 "(es·, does he/she have anorexia 

b. If the answer til question 2!i is "Yes",does he/she ha~e weight JO$$ 

3. Are' you recommending medical marijuana {or this patient due to nausea i!lnd v~miting 

associated with cancer chemothQrapy 

B'Y'es 

DY~ 

'DYes 

DYes 

DYes 

ONo 

DNo, 

a. If the answer to question 3 Is "Yes", hasl:he patient failed 10 respond to conventionel 0' Yes 0 No 

~ntlemetle t.-eatments 

b. If the answer to questlon,3a is "YI;lS·, please describe what thoss lreatments were (medi~t1on, dose, 

duration): 

c. What js the pl:;Jnned schedUle of chemotherapy 

4. If you answered °No" to items 2 & a above, what Is th~ raason you are n~commendIng medfcinaf use of 

marijuana!' , \, ' , 

C. ~'fc.{\,k.. ~iY\, 

CiI. 

Please provide evidenc~ published in a peer-reviewed scientIfic publ!eatlon to support the medicinal ).lse of 

manjuana for thIs purpose, '" 

,5. While on community supervision ('parole' thlil Department of Corr,eotitll)s 'only authorIZes the ' 

use of the ora! synthetre formulation of marlj~aoa,~!fjbe_Dapar.tr.net:lt..autl:ior.lzBs-tf:1is-patieflt's-El-y.$S---~0 

'--u"',s""e""'or meoicaJ marijuana, Will you be prescribing only the oralsynthettcfcrmulation . 

S. The patienfs accompanying Release of Information authorizes you to provlde'the 

Department with ourrent and future irn9rmation related to thIs issue. Do you agree to notify 

the Department's Medical Oireotor of any ohanges in your answers aoove 

DYes 

~o, 

ooc 14-01)3 (Rev. 7I31106j 

OOC3B0..200 

PDU-6655-3 000220

MAR/IS/2009/ViED 03: 05 PM 

FAX No, 

p, 004 

hr, l~1'J.c..." O'v .... \c..\ -:S:::'-C 

·.~Cd:::s(!:.,:,·f.,,""'~~ \....l-_~ _____ _ 

.... 

PfOISCrlbar's Nsm e (Print) 

Prascrlber'p SignaM, 

~, ~"'''' S(..~({"it..~ "'c..€.... oJ;~\c..~. vVI~ "'\.!>'CJ~ . 

Ucense#: ~. "'lIcense type: 

. Phone Numbec 

""""be


, 

I . 

I· 

.j 

i 

, 

I·. 

I 

I 

I 

I 

i 

I 



URE OF HEALTH INFORMATION 

I, hereby authorize the use or disclosure of my health information 

as described beiow. The following individual or organization is authorized to m~ke the disclosure: 

NAME: 'Ttl Gr \(Y\:-U\t co..l (\ J I '(\ \ Gs 

ADDRESS: \ 8' \ 't:, \O\..:)-t rl /We., Y'\G h+ ZA ~ . 

, b0~ k.,\/\A .... L w"f:: q 2:;1,) ~ 'S.- , , 

(l.-\X') ~'1oq- ColbY:>' tux (LlJ'S")B£F\- Lp31~ 

The type and date( s) of information to be used or disclosed is as follows: 

O--rvu\\~~'m~~m v..(.A

· STATE OF WASHINGTON . 



April 29, 2009 

Dear Ms .••• 

Your Medicinal Use of Marijuana request was received on April 8, 2009. Upon review by the 

Department .of Corrections' Health Services p~ysician, your request has been denied. 

Yop. may appeal this decision by sending your written request within 15 business days of receiving 


Karen Daniels; Assistant Secretary 

C01nmunity Corrections Division 


P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional information that was not inchided with your original request. 

Appeals that do not contafu. new information will be denied. You will receive a resp~mse to your 

appeal request within 30 days of receipt. .. . 



-------KD:mdl------------------------~--------------~------~~------~~~cc: 

Brooks Raymond, Commu:trity Corrections Supervisor 

Joshua Bryan, Community Corrections Officer 

Field File - _ .. 


G. B. Smith, M.D. 

301 S. 320 th . 

Federal Way, WA 98003 

"' 


\. "CC)'cled paper 

, 

\ 

PDU-6655-3 000223

1 


i 

From: 

Sent: 

To: 

Cc: . 

Subject: 


Thursday, APril 09, 2009 12:54 PM . 

Distefano, Monica J. Daniels, Karen R. (DOC) 

for authorization for use of medical marijuana does not me~t criteria for medical necessity. 

, 1 

PDU-6655-3 000224

i 

J 

j 

! 

. APR 082009 



l\IIedicinal Use of Marijuana Verification 

OFFENDER 1.0. DATA: Dept of Corre~tion9 ( /\ /.~ l)~ J 1.---. 

Health Services [1 0 l{! If /JO C 




offenders after t~ey have been convicted of a felony. The above named patient is currently under supervision by the 

'Department Supervision is designed to help the offender avoid those environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contiibuting factor in an individual's criminality. Accordingly it's usual that tbe court or 

the Department of CorrectioRs will impose a condition of supervision that the offender not use, or possess illicit drugs, 


been recommended. The belo.w verification is to determine the. legitimacy of their claim. Thank you' in advance for you·r. 



2. Are you recommending medical marijuana for this patient due fa a diagn'osis of Acquired 



h. If the anS'Ner· to question 28 is ·Yes·, does he/she·have weight loss 

~Yes 

DYes 

DYes 

DYes 

DNa 

181 No 

DNa 

DNo 

3. Are you recommending medical marijuana for this· patient due to nausea and vomiting 


a. If the answer to question 3 is ·Yes", has the patient failed to respond to conven~ional 

antiemetic treatments . . . 

DYe~ 

~' 

DYes 


duration): . 

WNo 

DNo 


4 .. If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use of· 

5. 

a. 

marijuana, ~., - .-1'v~~. £i ~ . 

~&t: ~ ·Wv " ~kQ .~U~ .~. ~:JJJ)~~~ 

Please provide evidence pUbliShe~eitiewed 

Rf-' . 

scientific publication to support the~ed~ai 

. 

~e of 

marijuana fOr1Fiis pu~~:. 1\ !\ 

t.Hf.. ~ .' . )O-oJfM 

The patient's accomp'Emying Release of Information authorizes you to provide the 


the Department's Medical Director of any chan~es in your answers above 

~Yes 'ONe 

PDU-6655-3 000225 

nnr..:'I110 9.00.

[,,'B-' 5fi1/#1 '{iYlQ 

prescriber's Name ,(print) ,.-j 7 

Bfb~;-'ML) 

ff' .3 Prescriber's Signature I 

License #: (Y\.. D 000 25 License type:- 

Date 

Prescriber's Address 3 0 f s-. "3 d- 0-1'4' '. Phone Number 

r ...e ) - Vt) tj, \,j / 1/0 t{ '- q'j[OO ,3 

Prescriber: please return this form and the patient's P~ease of Information to: . 



Washington State Department o~ Corrections 

P.O Box41123 

Olympia, WA 98504-2113 


.../' . 

, have reviewed this verification form a rnd that use of medical marijuana by this patient 

(check one) lOis . IS not . 

con~[stent 'Nith QOC ~::;oticy'. 1 

,Gla ._,+euj&~:,,»_ 

,Physician-sN"uTie'(printj " ,.-.-_. --~. -----:-- 

~h~ 

PhySician!s Signature . 

Date 

'Instructions, to DOC Physician: 


,1. Email your finding above to the Assistant Secretary for Community Corrections_ 

2" File this form and the accompanying Release of Information in Liberty as a Community Corrections Health Record. 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andlor federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infomiation without the specific written consent of the person to whom it pertains, or as otherwise, ' 


' 

PDU-6655-3 000226


DEPARTMENT OF CORRECTlONS 


April 29, 2009 . 

MountVemon, WA 98273 

Dear Mr._ 

Your Medicinal Use o'fMarijuana request was received on April 27, 2009. Upon review by the 

Department of Corrections' Health Services ;physician, your request has been denied . 

. . You may appeal this decision by sending your written request within 15 business days of receiving 



Commurrity ~Corrections Division 

'Department of Corrections 

P.O. Box 41126 

Olympia,WA 98504-1126 


Appeals that do not contain new nlformation will be denied. You will receive a response to your' 

. appeal reguest within 30 days of receipt. . . . 

SinC~er~IY') ., _ . 

. -(/~ 

" .' 


CornmUJ."1i.ty Correct;ons Division 

,. 

------~KD.md~--------~--------------------~__ ~------------------------------------- 

cc: Gregg Freeman, Community Corrections Supervisor 

Suzanne St. Clair, Community Corrections Officer 

FieldFile_ 

Physician's Office: . 


1813 l30 th Ave. NE, Ste,·210 



t; recycled pnper 

PDU-6655-3 00022,(


From: 

, Sent: 

To: 

Cc: 

Subject: 


. Wednesday, April 29, 200910:44 AM 

. Distefano, Monica J. (DOC); Daniels, Karen R. (DOC) 

~en(DOC) 

___ MM Request 

_ request for authorization for use of medical ma~ijuana 'does not meet criteria f~r J:T1e~ical ne~essity .. 

2 

PDU:,6655-3 000228


'DEPARTMENT OF CORRECTIONS 



RECEIVED 

APR 272009 

D"ept of Corrections Health Services 



. offenders after they have been convicted of a felony. The above named· patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead to their 9riminal 

behavior. Often illicit drug .use is a contributing factor in an individual's criminafity. Accordingly it's usual that the court or 

the Depa'rtment of Corrections will impose a condition of supervision that the offender not use, or possess illiCit drugs, 

including marijuana. This offender has claimed that they have a condition'for which the medicinal use of marijuana has 

been recommended. The below Verification is to determine the legitimacy of their claim. Thank you in advance for you~ 



6jYes 

DNo 

2. Are you recommending medical marijuana for this patient due to a diagnqsis of Acquired 


3. 


b. If the answer to question 

Are you recommending medic 

associated with cancer chem l 

a. If the answer to questi( 

antiemetic treatments' 

l . 

~~rl1cL\ 

" -I",,,!s he/she have weight loss 

(0 naUsea and vomiting 

,d to respond to conventional 

DYes 

DYes 

DYes 

DYes 

DYes 

b. If the answer to quesf 

~ttt)~~ 

"'hat those treatments were (meaication, dose, 

duration): 

. i 

. I 

c. What is the planned 

i 

gNo 

DNo 

DNo 

,r.' 

[1J No 

DNo 

\ . 

4. If you answered "No" to items 2 &13 above, what is the reason you are recolTlmending medicinal use of 

marijuana . \ ~" . 

c.....'I\.0J7.:J ~lc... ~.", 


marijuana for this purpose. I . 

I 


Department with current and future information related to this issue. '00 you agree to notify 


DYes ~o 


. - 


I 

I 

PDU-6655-3 000229

" 

\) /"", ·\~\.oyv\~" Or ve,.. l.d 5" (( QP,CI

• M, .' • 

.~ 

" 

Ii 

l'i~1arijuana for r,:~l . 

Patient Name·: 

I 

1 

I· 

I 

I 

I. 

i· 

8ig:nature of l'hysichi:li:.:.~.,. __ :"'-:--J_~':4.::..r::L'!:J."::::::;~.~2:..~~:::::::::::~~_ 

.'~il;}ma~ 0,' Ot~;ii~tG' 

. :.;.~{I.;··' 

Today's date: ·29 Au' , t-';Z.;...;·O'-'O:....;S'--:--'-_ . Expiiiatkin date: __ £l...J:1gg~~~.~!l!... ___ _ 

. j o' • 

Risks and benefits of' i!Hi)c::ll marijnari~: 

.'i,f' .. i '-\. 

. . . ~-i. ..' ..,'. . • 

Under Washington statt:t~~y, the use of medical ma~ijuahi~

. I, Offender Name 



rllc'p C/r~Ur'Lto 

release a copy of - . ..... - 

.. 

-.' to: 

NAME 

REPRESENTING 

MAILING ADDRESS 

CITY, STATE, ZIP CODE 

hereby authorize 

AUTHORIZATION FOR RELEASE OF 

CUSTODIAL iNFORMATION .' 

Vi ;;'S-.J (, "1'1- (,,0 1 r 

Releasing Authority Name.I)r-,O,r~aJ2J 

Name {}Q...p ~ ci 0..H, /' -e c/,:ct'y)CJ 

. Representing . ~ CZ--v( C'\....Q s(. -G~'· 

Mailing.Address --= ' Sit S', D> A..Jot. 3+. 

City, State ZipCode I. i / .. '\ . 

. JlvC:-+- " (/....x.-r fI. OY\ f/v ~ 

! 

. The information is released for the following reasons: 

Enter Reasons 

/0 'U~i~o- ~ ~ yr~ ~ f'o-L 

THE FOLLOWING INFORMATION MAY BE RELEASED: . 

D 

D 

D 

D 

Educational History 

Random UfA Results 

Progress in Treatment' 

Presentence Report 

D· Criminal History 

D 

Reports to Court I Board 

D . Assessment or Reassessment of Risk Forms· 

o LSI/RMIIOAP Interview Data 

.0. ,. C~urt or Board Orders 4.,.~ fae~F, 

~ Other (Specif~): f1U~3(:.· C~ an0'l-' I 

., Itc-Pa- /..e.J tv f1{O-r ('/I o-e . tu~ 

. . . 9"-1'7' -O~ ()~/rr-/ CccJZlcJ-A ~ /J . 

.' . f/'-esc-/'! Q{..roV\ (tY1.t1!-r,' rV~ 

NOTE: For release of medical: dental, and mental health information, use DOC 13-035, ALI 

Health Information. 

orization for Disclosure of 

For release of drug and alcohol treatment information, use DOC 14-303, Chemical Dependency - Consent for the 

Release of Confiden~iallnformatfon, 

'if releasing to criminal justice agencies. 

/ 

(CONSENT IS SUBJECT TO REVOCATION AT ANYTIME.) 

.L{ --I" -0 t 

DATE 

WITNESS 

PROHIBITION ON RED IS CLOSURE: THIS FORM HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALLY 

IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED. ANY AUTHORIZATION SPECIFYING "ANY AND 

ALL INFORMATION" SHALL NOT BE HONORED. . . 

The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and 

will be redacted in the event of such a request. This form is governed by Executive Order 00.03, RCW 42.56, and RCW 40.14, 

1 


PDU-6655-3 000232



P,O, Box 41100· Olympia, Washington 98504·1100 

April 24, 2009 

j 

I 

i 

\ 

\ 

I 

I 

I 

\ .,----. 

, Clarkston W A 99403 

DearMs._ 

I received your request to appeal the denial of your initial Medicinal Use of Marijuana 

Verification. . 

In the interest of public safety and protection of the community at large, I find your request for 

Medicinal Use of Marijuana, while under the supervision of the D~artment of Corrections, is 

denied. ' ' . 

However, in reviewing your paperwork, '1 see that your physician has prescribed the use of 

Marinol. Please work with your CCO, to provide him with the necessary verification so that you 

will not be violated while taking this prescription. 

I would encourage you to continue to program in a positive manner, following the direction of' 

your assigned CCO and your conditions of supervision. . 

s:;J ........ _c... 



KD:md 

cc: April Flower, Community Corrections Supervisor 

Kyle Helffi, Community Corrections Officer 

Field File - _ -, 

Physician's Office: " 

Thomas Orvald 


1813 Both Ave. NE, #210 

Bellevue, W A, 98005 


~ recycled puper 

PDU-6655-3 000233

:--:7:;'~!;.~:1::7"'!:'·· 

I 

i 

I 

! I. 

PDU-6655-3000234

i···· 

I 

I 

, 

I 

! . 

i 

i 

_----c'!d""'"'-"/U1L£Lp.tL.c:LCJ~bt:ctad::jjxJd£s_tZl.J-AJit 

---',;..f~ -Pi{JIVi Y1f1.t1 f; k lil~.U.~I!. a....-Ikt'-s..Je£4.11ltJ.1SL'---· - 

__ ~i; Vl-\....-j2oJ±/..a nd in kDdJ.1L {A t1AL +0' )-jVL( .t1A I/I:'-..l_'. __ 

__ rI-L-1Vz..I..-Jld.lkiCh ... ' _ ~~n Xy]t(JntParah!~ 

!kJi-e5- fo I0J y} IJ:JJ;:; tJ y tft n ~ o+he r OlRdiCinLL.. . 

iYhcwl enduY-e dol ,ov.e,y- i1z-e Lf--'(lXYS~S 7- . 

i1o()£/,VLCf--5ar,

PDU-6655-3 000236

I 

I' 

I 



P.O. Bo)( 41100· Olympia. Washington 96504-1100 

FeblUary 20, 2009 

Clarkston W A 99403 

Dear Ms._ 

Your Medicinal Use of Marijuana request was received on February 9,2009. Upon review by the 

Department of Corrections' Health Services physician, your request has bee~ denied. 


which is on or before March 16, 2009. Please send your request to the address below: . 




P.O. Box 41126 

Olympia, WA 98504-1126 

Your request.must provide additional information that was not included with your 9riginal·request. 



Sincerely,' . 



KD:md 

_.__ cc~ ___ ApriLElo..werr-Community-Cor:r.ections-Super-v.:isor:---- 

. Kyle Helm; Community Corrections Officer .. 

Field File ••• 


Thomas Orvald 

THCFMedical Clinics 

1813 Both Ave:NE, #410 


. "Working Together for SAFE Communities" 

PDU-6655-3 000237

5j(B L C W~SEM5 . . ; 

cm:~EVANS, TRISTA R. 

324594 11/04/1974 

R.E;c ..... 

. J£::.lVeo 

/ ........ 

518087679 

(~ STATI!OFWASHINGTON 

. FEB 09 2009 . 

......, DePARTMSNl OF COFtlttCTIONS 

MedicInal Use of Marijuana Verification 

Depl"ofc . 

OlT~ctions HI" 

ea til ,:,ervices 

To be filled out by Prescrlbet: 

Dear Prescriber,· . 

By staw statute the Washington State Department of Corrections Is charged with the responsibility to sup~~ise sOn)e 

offendel'S after they have been convicted of a felony. The above named patIent is currently under supervtslon by the 

Departroent. SupervIsion Is designed to help the offender ~void those environments or situations that lead to their criminal 

behavior. Often illicit dl'Ug use is a contributing factor in an individual's crIminallty_ Accordingly it's usual that the court: or 

th~ Department of Cotractions will Impose a condition of supervision that the offender not use, or possess ilUcitdrlJgs, 

Including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has 

been recommended_ The belOw. verlfication is to determine the legitimacy of their clclim. Thank you in advance for your 

assistance. If you have questions please feel free to perSOnally contact the Medical.Director of the Department at (360) 

725--8700. . . . / 

1. Is tl)is patient under your care . rz(yes 0 No 

2- Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 

Immunodeficiency Syndrome (AIDS) DYes ~o 

a. If the answer to question 2 is 'Yes', does he/she have anorexia OYe.s oNo 

b. If the answer to question 28 is "Yes", ~oes he/she have weight loss7 OVes ONo 

3. Are you recommending medica! marijuana for this patient due to nausea and ~omiting 

associated with cancer chemotherapy Dyes ~. 

a. If the answer to question 3 is "Yes", has the patientfalied to respond to conventional 

antiemetic treatments DYes ONo 

b_ 

If the answer to question 3a is "Yes', please descrlbe what thOl;lB treatments were (madication. dose, 

duration): '. 

c. . What is the planned schedule of che~othe.-apy 

4. . If you answered "No· to Items 2. & 3 above, what is the reason you are r.ecornmending medicinal use of 

iilarijuana 

a. Please provide evidence published in a peer-reviewed sCientific publication to SlJpport the .medicinal use of 


5. 

VYhile on community supervislOn(;Parole") the Department of Corr~tions on1y-iUffiOi1zes trie ~yLe-s-"-. -':--O-N-O--- 

use of the ~r'. synt~~tfc:.f!~ul.~~90 .. ~ ~a~JJuana. If the Department authorizes this patient's arYes. 

use of medIcal marijuana, wUr you be prescribing only the oral synthetio formulation 

e. The patient's accompanying Release of InformatIon authorizes you to provide the 

Department with current an~ future Information related to ttl1S Issue. Dei you agree to notify 

the Oepartment's Medical Director of any changes in your answers above 

oNo 

DOC 1+053 (Rev. 7/31/08) 

D00380.200 

PDU-6655-3 000238

nl"" LH~t:.I

_ _ ••• M 

nr Ln;:,l:.I':.Jl:. I 

t- HX 

/_ .. Yfl 7 Y1J Uc'L. 

(~ STATE OF WASHINGTON 

....., DEPARTMENT OF CORRECTIONS 


OF HEALTH INF:ORMA 

EVANS, TRISTA R. 

324594 11/04/1974 

518087679 . 

___ , hereby authorize the use or disclosure of my health Information 

to make the disclosure: 

p.l 

.. 


Purpose for dlsolosure:, _____________ ..,._----------..,._-------- 

I understand that the Information In my health record may Include informatldn relating to sexually transmitted . 

infections, Acqu!red Immu~,defi~ienoy Syndrome (AIDS). or .rjy~nJ,mmunodeficien~ Virus (HIV). It may also'" 

Include,.!D!orF!l.ru~;EI~out~l5'tii/i\a\1loral. C!r. !ll~.m~1 hea.lth ~~f,Yr~ tr~atm.!!lJ.tfQr alcohol a\'ld .. 9~1.lS-~I:l~!,:,_ ~ ...... _. __ ._ ....... . 

This Information may be disclosed to and used by the following individual or organization: 



NAME: WashllTll'lion State Department Of Correc1ions 

POBox41t~ 

ADDRESS: Olympia, WA ')l594=2113 

I understand that I have a right· to revoke this authorization at any time. I understand thatif I revoke this 

authorization! must do so in writing and present my written revocation to the Health Information Management 

Department I understand that the revocation will not apply to information that has already been released in 

response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event,· 

or condition: . . (if left blai"ik, authorization wiil expire six {B) months from signing). 

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this 

authorization. I need not sign this form In order to assure treatment. I I.,Inderstand that I may Inspect or copy the 

information to be used or disclosed. as provided In CFR 164.524 and RCW 70.02. ! understand that any disclosure. 

of Information carries with it the potential for an unauthorized redisclQSLlre and may not be protected by federal or 

state ccnfideli'Jaiity rules. If I have quesi:ions about disclosure of my health Information, I may contact the 

RHITfdesignee of the facility: . =~:::::::1·:;;:::;:",1-7.;-OL.--.--- . ___ ........ _ .. 

,- 

;;, _ ._ n

" mCF'Medical ClinicS 

i813 13tfD Ave N.E. #210 

BeiIevue; WA 9800S 

Phone: 425-869-6186 or 1-800-7l3-O188 

Far. 425-869-63711 

www.thc-foundation.org or nw.hem,p.org' 

DQcumentaticn ~fMerlica1 A~morlza.tioli to,PosseSS M:trijuans.. foY Medical' 

P~o,seS in Was~ingtOn State ' 

The text of this .o.t. I if:. '1 II - 'i . hingtoD. S~ Medical Assoc!ation. 

. J ate 

I, Thomas Orvaid, ~ ll- physician licensed in the S~ ~W~ .r am'tIeatiDg' , ' 

t:be ab,ove named'patient' fill" 8: t~ illness or a ~ ~dition as defined in', ' , 

RC,W 69.51AOIO~ Ih!i1le ad.vi,~ the ~O"."e ~e4,paii~,about~e p~ risks 

and b~efits of~ ~ca1, ~,o(meri~ I have ~ the'abov:e~ed', . 

patient's medical histOry ~d medic:al ~Ddition.. Jt'is mY. Diedical opinion that ~e 

potential benefits of the medical use of marijuana. would llke1y outweigh the health 

risks for this, patient. . . .'.' . ' 

S~atur~ofP~ician: 

. ~L!71&u.A OR.viR!e~'c~ 

, ." ~M.D. WA#MJ)·uu016180 

--....... • '0. 

T oday's ~te= " 'IiAR t i -- '. Expirati,!n date: -' ~. MAR ! 5 2009 : 

~~ks ~tl ben~fits of med.ical mariju~a: 

U1:lder WashWgton state law, the us~ of medical ~ is nav,;, p~ssible ~ so~ 

patients with terminal Or dehiiitating, illnesses. The laws're£l11a1jtig~, ~CW'6951A) . 

aIlo"t'JS physician's to advi:se patients about the,risks and'benefitS of~e mediC3.1 use of 

.mEm~~.· . . t· .~ . 

. Th~ medical arid sci~c evidence-suPP,Crtirig the use ormedica:!' malijmma r~;rlmJ 

con.troversial in the mediGal commtm..itY. .. Net a.'l health ~ ~vjders believe that 

medical marijuana is safe or: effective and !rome prOviders f~ that it is a dangerous drug •. 

According to the Washington sbrte law the'benefits of~edic;al marijuana. ~ include. 

treating nausea and vomiting from chemotherapy; AIDS wasting syndrome; severe .: 

·muscle spasms from multiple sclerosis or other spasticitY disorders; ~~d: some __..__....._._.._._.._...._- 

___,...-. W.es-ofintractable·pain;--· ~'~-'~--'. . '. , 

, " 

Some of the risks of medical iriari.j~ may inchide possible long-term. effectS f.the 

briUn 'in ~e !U'eas of memory, CQOrdination and cognition; impairment of the ability to 

drive or operate beavy machinery; respiratory damage; possible lung Catloor. p~cal or 

psychological dependence.' , 

'., 

," .... 

" 

. -,'" 

-, ., .. 

PDU-6655-3 000241

CBR iviedicai~ inc 



l, 

, 

; 

To: MONICA DISTEFANO From: Melissa@Cbrmedical.cOm 

Fax: 360-586-0252 Date: ' 04/10/2009 

Phone: 360·725·8796 Pages: 

Re: 

-APPEAL 

o Urgent o For Review o Please Comment 0 Please Reply 0 Please Recycle 

Monica, 

Enclosed is the Appeal for the Medicinal Use of Marijuana for Mr. 

We 

sincerely appreciate the time and effort that you personaUy take in handling these issue,s 

on behalf of our patients. 

I have also enclosed ••• authorization from Dr. Mohammad H. Said and from Dr. 

Antoine Johnson. Additionally I have added more information on the conditions for which 

_suffers. 

Again thanks so much for your time and efforts., They truly are appreciated. 

Sincerely, 

I 

! 

Melissa LegSee 

509·570·2886 

CBR Medical, Inc, • 3115 E. Mission Ave, Spokane, Wa 99202 

Seattle Phone 206-774·6493 Fax2D6-418·6659 Spokane Phone 509·242·8624 Fax 509~340·2710 

Tri.Cities Phone 509-416·2267 Fax 509·340·2710 Vancouver Phone 360·635-6464 Fax 206-418·6659 

l 

----}- 

1 

.1 

i 

CONFIDENTIALITY NOTICE: This communication is intended for the sale use of the individual and 


exempt from disclosure under applicable law, You are hereby notified that any dissemination, 




PDU-6655-3 000242

I 

ClSR M,z;,!tIncan; !"c 



, 

I, 

r 

o Urgent 0 For Review 0 Plesse Comment 0 Please P..el1l~Y ,P Please Recycle 

'Comments: 

Y 

J 

!() u t/ ( , "f~" f 

' 

"--'d' 

( ,'r/ ' ."vf)(p{I '4 ( e r 

{/J j;Y!' ~~, t~i {!. , , 

;;7 _ e",',' 

#1t.Le/~~ 7 J 

..., 

,~"' 

t~~e:,f{ 

, , ;";'A;\ f2.AtJ 

~--------' --------'--,. -----A1/tztfr&u- tli _' __ : __ ' a ,_' ---:-_>--_ 

~ /1'-. Ii 

CBH M.edical, Inc. - 3115 E. Mission Ave 1 Spokane, Wa 99202 ~ 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509·242-8624 Fax 509-340-2710 1 

Tri-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 ' ~ 

CONFIDENTIALITY NOTICE: Tilis communication is intended ror the sole use of the individual and 

entity to whom it is addressed, and may contain information tllat is privileged, or confidential and 

exempt from disclosure under applicable law, 'You are hereby notified that any dissemination, 

distribution, or duplication of this communi~tion by someone olher than the intended addressee or its 


I 

; 

I , 

! 

~ 

I I 

~ 

, 

~ 

All information is Protected Under U.S. Federal Law 

·i 

1 

PDU-6655-3 000243

I 

I 

J 


STATE OFWASHllIIGTON 

OEPARTMENT OF CORRECTiONS 

Medicinal Use. of Marijuana Verification 


.. 

Dear Prescriber,. . 


offenders after they have been convicted of a felony_ The above named patient is currently under supervision by the 

Department. Supervision is deSigned to help the offender avoid those environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court' or 



been recommended, The below verification is to determine the legitimacy of their claim. Thank you in advance for your 


725-6700. . 

1. Is this patient under your care ~Yes DNo 

2, Are you recommending medical marijuana for his patient due to a diagnosiS of Acquired 


DYes 

9'fIIo 

a. If the answer to question'2 is "Yes', does helshe have anorexia DYes Ei1fo 

b. If the answer to question 2a is "Yes", does he/she have weight loss DYes Q-No 



DYes 

[31(0 . 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional Dyes ~ 

antiemetic treatments~ 


duration): 

~/V 

c. 

What is the planned schedule of ch6f.10therapy 

. jJ/~ 

4. If you answered "No" to iteljlsb2Ji above what,~]1e ~eas'f. you aret,recommending medicinal use of . 

marijuana 1wh'I.. ~ f'a.;J,.::. ~rr ~ --tA :5 f ,,.,

.- .. __ ._-_._---_. 





.I, Dr. Mohammad H. Said , am a physician licensed in the State of Washington 


RCW 69.51A.010. 



It is my medical opinion that the potential benefits of the medical use of marijuana may outweigh' 


Physician Name: __ ~D:.:..r. -"'M:.;;:o;.;.:h""an:..;,:1::..:.m.:;:a:,;:dc.;.H"" ..-'S::..::a::..:cid::.-__ WA License Number:. ___ M_D_O_OO_1_B_3_11_ 

Physician Signature: -.....,!h~--'--.-I:/dr-'---'. ~;...._~~ ____ Date: _--,-_0_2/_0_1/_2_00;...;9____ 

This recommendation expires on: 01/0412010 

Risks and benefits of medical marijuan.a 




The medical and scientific evidence supporting the use of medical marijuana remainS 

controversial in the medical community. Not all health care providers believe that medicClI 




sp!,!sms from multiple sclerosis or other spasticity disorders, glaucoma, and some types of 

. intractable pain. 

Some of the risks of-medical marijuana may include possible long-term effects of the brain in 

the a reas of memory, coordination and cognition; impairment of the ability to drive or operate 

heavy machinery; respiratory damage; possible lung cancer; and physical OF psychological 

dependence. 


. As this patient's "60 Day Supply", as stipulated by RCW 69.51 A. 040 (3)(b) and 

-'i------WAC-246-7-5-01-0j·this··Qualifying··Patient·ean"reaS0nably-expeGt-to-have-iFl-tl:1eir-P-Qsession~af.ld- 

, Need a total of no more than 24 Ounces of "Useable Marijuana" and no more than 15 Plants . 

. CBR Medical, Inc. 



Spokane: 509-242-8624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418-6659 


. CALL 509-570-2886 OR 509-570-6943 

PDU-6655-3 000245


DEPARTMENT OF CORRECTiONS 

P.O. Sox 41100' Olympia. Washington 98504-1100 

March 26~ 2009 

Otis Orchards, W A 99027 

Dear Mr._ 

Your Medicinal Use of Marijuana request was received on February 6, 2009. Upon review by the 

Departme:o.t of Corrections' Health Services physician, your request has been denied. 

Y QU may 'appeal this decision by sending your written request within 15 business days, on or before 

April 17, 2009. Please send your request to the address below: 


Community Corrections. Division 


P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional information that was not included with your original request . 



Katen Daniels, Assistant Secretary 


--KD:-m-::dc------- 

OO---- 

cc: 

Etta Molett, Community Corrections Supervisor 

William Fryer, Community CorrectionS Officer 

Field File 

Physician's Office: . 


CBR Medical, Inc_ 




~ tl.'Cyded papc:r 

PDU-6655-3 000246


From: 

Sent: 

To: 

Cc: 

Subject: . 

Johnson, Deborah A. (DOC) on behalf of Hammond, G. Steven (DOC) . 

Monday, February 23, 2009 4:36 PM 


·~OC). 

___ MM Request 

request for authorization for use of medical marijuana does not meet criteria for medical necessity .. 

.. _._----------- 

1 

PDU-6655-3000247



P.o. Box 41100· Olympia, Washington 98504·1100 

April 29, 2009 

Edmonds, W A 98026 

.DearMr._. 



. . 

In the interest ofpublic safety and protection of the community at large, I find your request for 

Medicinal Use Of Marijuana, while under the supervision of the Department of Corrections, is 

denie~. 

I 

i 

I would encourage you to continue to program it:J. a positive mann~r, following the direction of 

. your assigned CCO .and your conditions of supervision. . 



KD:md 

cc: Richard Kendo,Community Corrections Supervisor 

Michael Le_wis Community Corrections Officer 

Field File - . 


. Attn: Melissa Leggee 

CBRMedical 


Spo~ane, WA 99202 

---------~- ------------.-.--- 

o recycled p"pcr 

" Working Togetl"ier for SAFE Communities" 

PDU-6655-3 000248

1------ 

i 

I 

. t' 

n 

',: 

.( 

"'~-'-~7--""'-:r'''''':'~ -_.,'., .. , 

. -::'" 

"." 

PDU-6655-3 000249

.------.----:--.-~.- ..-.....__.._._---_._--- .-----...--~--------- 

·Jan, 23, 200911:48AM CBR Medical Inc, ~o,3192 

p, 116 

Spokan0, Wf:.. U9O. 

'fo: (nOQiCO_12t~)tf:..~CU]D. 

i-·rom.: rnel\~~f3t.L@ ttP~ _ 

". 

~'~'t:fio'- 02£22. I~O]~m I -".,~0-~C)1 __ 

. .. 

.-;-') 1" (l . ,j 

\J/ .,.) L",-:pr 

------_._------,---- 

--_._------_._----_._------_ .. _-----.------ 

CBR Medil;;,l!, Inc, - :111b E MIF'~lion Avu, (·;pOk

,------------------------------ -----------------_._- 

Jan. 23. 2009 11: 49AM CBR Medical Inc. 

No.3192 P. 2/6 

STATe OF WASHINGTON 

DEPARTMENT Of CORRECTIONS 

AUTHQRlZATION FOR DISCLOSURE 

OF INFORMATION 

I)FFFNfJer! 1.1' DAr", 

hereby authorize the USB Or disclosure of my health information 

or organization is authorized to make the disclosure: 

';A""" C~ 11: .•") (;:,/ 'f,;'" \. _ !1 '-t'" ( 

I,. Ivlc: ... ~ ~~'-:1"r== ,{ weI {

·· 

! 

Jan. 23. 2009 11 :49AM CBR Medical Inc. No.3192 P. 3/6 

OFI'ENOCR I.ll nATA' 

STATE OF WI'SHINGl·ON 

DEPARTnOENT OF CORRECTIONS 




l3y state statute the Washington State Department of Corrections is charged with the responsibility to supervise some 

offenders after they have been convicted of a felony. The above named patient is currently under sl,lpervision by the 

Department. Supervision is designed to help the offender avoid those environrnents or situations that lead to their criminal 

behavior. Often illi~it drug LIse is a contributing factor in an individual's Criminality. Accordingly it's usual that thei courtor 

the Departmerit of Corrections will impose a condition of supervision that the offender not LIse. or possess iUicit drugs, 



assistance. If you have questions please feel tree to personally contact the Medical Director of the Oepartmef]t at (360) 

~~ / 

1. Is this patienl under your car~ 1L:1Yes UNo /"" 

2. 

3 

Are you recommending medical marijuana for his patient due to a diagnosis of AcqLlired 



b. . If the answer to question 2a is ,"Yes', does he/she have weight loss 

DYes 

Are you recommending medical marijilana for this patient due to nausea and vomiting 

DYes 

associated with cancer chemotherC!PY 

8. If the answer to quastion 3 is "Yes",·has the patIent failed to respond to conventional 



duration): \ t\....... . 

N ...),;. \'\ fr \ \ V:.. \.'\ t- 

c. What is the planned schedule of chemotl1r;rapy 

~ ,.. iy (;:\ fr\; ll:.1 \-l. 

I.~ 

ElTes-a-No 

Q-.¥es-~.'--B~No 

... 

~' 

4. 

If you answered "No" to items 2 & 3 above, what is tile reaSOn you are recommending. medicinal use of 

- • 'l 

marijuana j' "\ \ \ .... . . . I,. ( ..... , '> J\J\I \.... 

ec~ .t~","t\........ \-I\!..':: C.l3R. -.f""'''1('~''..",..,,, "---" ........

i 

I 

I 

Jan. 23. 2009 11:50AM CBRMedical Inc. " l' 

/" 

No.3192 P. 4/6 

",'" 

l i 

,I /,•• 

r . 

//_., ;' 

~ /I.)'f... 10., 

~. 

/' .......---:.... ~ 

l I ~ ..... Jfe- .... 

PreScriber'sSignatl I -.-"~"•. 

' ....., 

1._ 

I 

~/. 

.6ale 

/ 

I 

License#: /i--;,p..."..,._';.:o~"\,. ~ 

t,

clan, 23, 2009 11: SOAM CBR Me~ical Inc, No,3192 p, 5/6. 

Documentation of Medical Authorization to Possess ivlarijuana 

for Medical Purposes in W~$hjngtan State 

PATIENT NAME: ___ ~ 

DATEOF·BIRTH:~ 

-', 

I, ____ Antoine Johnson ,am a physician Ji\::ensed in the State of Washington 

and I am treating th~ abrNH pRti'mt for !1 terminal illness or a debilitating condition as defined by 

RCW 69.S'IA.OiD. 

I have advised the above named pati~nt about the potential risks and benefits of the medical use 

of marijuana, I have assEissp-d thA !1bOVfl n!1med patient's medical hi~tory ~ncl mAdir.;o1 I!9nditiqn. 

It is my medical opinion thatthe potential benefits af the medical use of marijuana may outweigh·· . 


Physician Name: _...-:0:.:[,-,. A,-,n'""t~oi.:..:n::

I 

! 



P.o. Box 41100· Olympia, Washington 98504-1100 

March 26, 2009 

Edmonds, W A 98026 

Dear Mr._ 

Your Medicinal Use of Marijuana request was received on March 4,2009. Upon review by the 


You may appeal this decision by sending your written request within 15 business days, on or before 





P.O. Box 41126 

Olympia, WA 98504-1126 


Appeals that do not contain new infonnation will be denied: You will receive a response to your 


. Sincerely, j 

I 



-···-----K15:n:icf---------------·--------···-----------.--------.--------,.----- 

cc: 

~i»' ""' tt!cycled . puper 

Richard Kendo, Community Corrections Supervisol' 

. Richard Hooper, Community Correc~ons Officer 

Field File 


Attn: Melissa Leggee . 

CBR Medical, Inc~ 



U Working Together for SAFE Communities" 

PDU-6655-3000255

,_. 

! 

j 

1 


From: 

Sent: 

To: 

Cc: 

Subject: 


Friday, March 06, 2009 9:10AM 

Daniels, Karen R. (DOC); Distefano, Monica J. (DOC) 

Hammond, G 

MM Requ 

I· The followlng requests for authorization for use of medical marijuana do not meet critorla for medical necessity: 

._=--_._._---------_ .. _----_._------_ .. _-_ .. _ .. _--_. ------.---.-----..... ".---.. -------.---~---.,..---.-.-~ ..... . 

1 

PDU-6655-3 000256

,- ...._..._._... -_......- .... ... ....••........._... 

0;3/.04/2009 14:08 2064186659 

CBR MEDICAL 

PAGE 01 

I Fax 

·111 




o Urgent 0 For Review 0 Please Comment D Please Reply D Please Recycle 

._----_._. ---._-----_._--- 

._---------- 

CBR Medical, 1110. - 3115 E. Mission Ave, Spokane, INa 99202 

Seattle Phone 206·774-6493 F:'OX 206-416-6659 Spokane Phone 509-2.42-6624 Fax 509-340.:2.710 

Tn-Cities Phone 509·416-2267 Fax 509·340·2710 'Vanoouver Phone 3S0.-635·S464 Fax 206-418-6669 

CONFIDENilALlIY NOTICE: This communic:ation is intended fa!' the sole use of the individuai and 

entity to whom it is addressed, and may contain information that is privileged, or confidential and' 

exempt froln disclo5Llre under apPlIcable law. You are hereby notified that any dissemination, 


designated agent ts strictly prohibited. - 

Ail Information is Protected Utid~r U.S. Federall..aw 

PDU-6655-3 000257

63/64/2609 14:08 2654185559 CBR MEDICAL . PAGE 62 

(~ STATe OF WASHINc;lTON . 

IJiULf DEPA~TMENT OF CORRECTIONS 

AUTHORIZAiiON FOR DISCLOSURE 

~'W"r .. 

OF,,"NO~R 1.0. ~~TA: 

hereby authorize the use or disclosure of my health' information 

as described below. The following individual or organization is authorized .to make the discloslJre: 

NAME; 

ADDRESS; 

C2B R A1edr-~( '''-£'1. c. 

" 1 J - .- M I rI 

,'22z>farl'; 1j CFI1Parllt51) prDhibirdl~~/tlSllr. 

, "[INs InjiJl'malion withour tilt sptci/k !Vrim" CbHla"1 o/th. p'fJon ta II'lwm It pertains, or as atlImvi .. permille

- , --, ---------, 

I 

i 03/04/2009 14:08 

1 

--------------------.. ------------------.--- 

2064186659 CBR MEDICAL, 

PAGE 03 

11""'~IIn"A,,~ 

.1" '\. 

l~) STATEOrWASHll-IGTON 

IIJIULr' DEPARTMENT OF CORREC'TlONS 


OFFIlNOER I,D. OATil! 

TO be fined out by Prescriber:' 


By state statl:lte the Washington State Department of Correotions is charged With the responsibility to supervise some 

offenders after they have been c,onvicted of a felony_ The above named patient is currently under supervision by, the 

Oepartment Supervision is designed to help the offender avoid those environments or situations that lead to their criminal 

beha,,;or. 01ten illicit drug use is a confributing factor in an individual's crimil'lai1ty. ACCr;lrdingiy it's usual that the court or 

the Department of Correctlons will impose a condition of supervision that the Offender not use, or possess illicit drugs, 


been recommended_ The below verifica1ion is to determine the legitimacy of their claim. Thank you in advance for yout 

aasistance. If you have questions please feel free to,personally contact the Medical Director of tne Department -at (360) 

725-8700. '/ 

1. Is this patfent under your care [] Yes D No 

2. 

3. 

Are you recommending medical marijuana for his patient due to a diagnosis of Acqulrecl 

Immunodeficiency Syndrome (AIDS) , 

a. If the answer to question 2,iS "Yes", does he/she have anorexia 

b. If the aMwer to question 28 is "Yes", does helshe have weight los!> 

, ' 

DYes 

, DYes 

DYes 

Are you recommending medical marijuana for this patient dlle to nausea and vomiting DYes 


a. If the answer 10 question 3 is "Yes", has the patientfailed to respond to convGntional Dyes 


b. If the answer to question 3a is "Yes". please describe what those treatments were (medication, dose, 

duration): 

~ 

rt; 

GNO 

~ 

c. What is the pl13nned schedule of chemotherapy 

4_ ' 

If you answered "No" to i\emS 2 &. 3 above, what is tht'O reason yo~re recommepding medidn~. ~ ft 

marijtlana', Q lA {o~ ; C. HLc..J.~ .. Yte'J, 'f(Sr~lttC...1 +. i>"'\"'V'. fU..d\. 

--tl~~ , . 

_______ ~ __ ~~~;~~~~~":;~~~brr~::;i~~~t~~bjt~~~rt ::~id",1 ~:~~_ ... 

5. While on community supervision ("parole") the Department of Corrections only authorizes the , 

DYes 

use of medical marijuana, will you be prescribing only the oral synthetic formulation . 

, . 6. ' The patient's accompanying Release of Information authorizes you to provide the , 

Department with current and future information related to this issue. Do you agree to notify 0 Yes . No 


DOC 14-053 (I'(sv. 7J31J08) 


PDU-6655-3 000259

03/04/2009 14:08 2064186659 CBR MEDICAL 

PAGE· 04 

Presorib(!r',. Signature 

. I.icense~: License type: 

PrescriJ:ler'sAddress ;51/5:.E:.. d'sS/"i)n Phone Number 

. SPI;) t:an.J.. W c.... 7' 7 t.. b t.. 

Prescr!ber: please return this form ~nd the patient's Release of Information to: 

5l) Cf -,. '12 _.8'(P Z ~-( 

. 57)'7 - 5'7{) - d. ;r~~ 


Health Services Di:vision 

Washington State Department of CorrectiOns 

PO Box 41123 

Olympia, WA 98504-2113 

To be fiiied out by DOC Physician: 

I have reviewed thisllerification form and find that use of medical marijuana b\l this patient 

(check on~) lOis. 0 is not . 

cons istent with DO.C Policy~ 

PhY$i

03/04/2009 14:08 2064186659 CBR MEDICAL PAGE 05 

--.---",--------------:---------~-:------------ 


for Medical Purposes fn Washington State 

. PATIENT NAME: ___ ~_~~~~~ __ DATE OF BIRTH:~ 

I, Dr. Mohammad H_ Said , am a physician licensed in the S~ate of Washington 

a'nd 1 am treating the above patient for a terminal illness or a debilitating condition as defined by· 

RCW 69.51A.01 O. 





. Physician Name: _-.:D:;,:r;,.. M~o:..::ha::.m:..::m.:..:.a::.:d:..H:..:.. :...;' S::.:a~id=--_.,.... WA License Number:. __.;..M_D_O_O_01_8_3_1_1 

Physician·Signature: __ 

. ~p-'A 

........ '_·.+H.;....· 

.._) 

..... ·'-·,,_......... 

This recommendation expires on: 01/0912010. 

_f ___ Date: 

0212112009 


Under Washington law, the use of medical marijuana: is now PlSrmissible for some patients 

with terminal or debilitating illnesses. Thl\! law regulating this (RCW 69.51A) allows physicians 

to advise patients about lhe risks and benefits of the medical use of manjuana. 

The medicai and scientific evidence supporting the use of medical marijuana remains 

controversial in the medical community~ Not all Maim ca~ providers believE! that medical 


According to the Washington State law the benefits of medical marij1,1ana may include 

treating rl'

. CBR iViedicai, inc 

•• 



To: MONICA DISTEFANO From: Melissa@cbrmedical.com 

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Fax: 360-586-0252 Date: 04/1012009 

Phonal 360-725-8796 Pagas: 

_Re_: __ -=I1111111=======-___________________ 

DO __ CIIIII~-_A_PP_~ __ L ________ 

o Urgent o ~orReview o Please Comment 0 Please Reply . 0 Please Recycle 

Monica, . 

Enclosed is the Appeal for the Medicinal Use of Marijua~a for Mr. _ 

We 

s.incerely appreciated the time and effort that you personally take in handling these issues 


We are also in receipt of two letters from the DOC dated February 20 th , 2009 and March 

26th, 2009, Please note that the request received' on March 4 th , 2009 is the appeal and not 

the original request 

I have also enclosed •••• medical records and his authorization from Dr. Mohammad 

H. Said and from Dr. Antoine Johnson. 

Again thanks so much for your time anti effoi1:s. They tmly are app,c;ciated. 

Sincerely, 

Melissa Leggee' 

509·570-2886 

------------------- ----.--------. .-------"-..--------~---.. 

CBR Medical, Inc. - 3115 E. Mission Ave, Spokane, Wa 99202' 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-271 0 


CONFIDENTIAliTY NOTICE: This communication is intended for the sale Lise of the individual and 


exempt from disclosLlre under applicable law. YOLI are hereby notified that any dissemination, 



All Infonnation is Protected Under U_S. Federal Law 

PDU-6655-3 000262

........ ---_.._...._......._.... .... ~ ....".......... -...._.' ....__.....--- '":.. _..- ..........---. -_ ..__.............-_.. . 

STATE OF"'IASHINGTON 


P.o. Box 41100' Olympia, Washington 98504-'1100 

March 26, 2009 

Edmonds, WA 98026 

Dear Mr._ 

Your Medicinal Use of Marijuana request was recelved on March 4,2009. Upon review bYtl1e 




Karen Danie1s, Assistant Secretary 

Community Corrt;:ctions Division 

. Department of Corrections 

P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional infonnation that was not included with your original request. 

Appeals that do not contain new infOlmation will be denied. You will receive a response' to your 

appeal.request within 30 days of receipt. . 

Karen Daniels, Assistant. Secretary , 

Community Con'ection~ Division ! 

rn~ 1 

cc~ --R:i"chard'Kend

ST,\T: OF WAS"INGTON 


P 0 E.j:;: 4, 100 2 Olymr:·ia. VVasllir,gtor. 98:'504.·j \.GG 

february 20,2009 

Deari'vfr_ 

Your Medicinai Use of Marijuan.a request was received on January 23, 2009. Upon review by the 

Departm~nt of Con·ections' Health Services physician, your request has been denied. 


which is on or before March 16, 2009. Please send your request to the address below: 



Department of COlTections 

P.o. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional infonnation that wa,s not included with your original request. 



SincereI~ .. "~. . 

. '-{'~J/ h n ~~ 

~~I./'-~ ~ . 


Community Con·ections Division 

; 

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KD:md . 

cc: Richard Kendo, Community COITections Supervisor 

__._______..Ri.chaJ:dBo~r:nmunity-Corrections.Qffi.c.eL 

. Field File -_ 


lfAl~n·~l:i1..iili~~~ill';.~g:ge.~ 

·CBR Medical 

3115 E. Mission Ave . 

. Spokane, WA 99202. 

"Working Tog;:ther for SAFE Communities" 

---------.,--.. ------... -.---.--.--------t--··· 

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PDU-6655-3 000264

CISR MedicaIT, Inr.c 



~o: /rk,C)..;.· eCL t2s-f-e·bA..t1 0 .~,T!..la.J;~s,sa e L-~l3g !i..ed,-ca...-! ~c-Dfi1 

r::oc= :3&0 ~ £23: & -- o; S--.:; Date< '{c!J.) 0 ~ . . _.' . 

9' ~ Pages: 

ee: 

o lilrgent 0 For Review 0 PDease Comment . 0 Please Iileply CI Please Recycle 

• Comments: 

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-;-------------- -... ---- 

. =. 

-----.-.-~.-.--.---------------------------- -----_ ..... - --- - . 

CBR Medical, Inc. ~ 3115 E. Mission Ave, Spokane, Wa 99202 

Seattle Phone 206-774-6493 Fax 206-~ 18-6659 Spokane' Phone 509-242-8624 Fax 509-340-2710 


CONFIDENTIALITY NOTICE: This communication is intended for tile sole use of theindividual·and 


exempt from disclosure under applicable law. You are hereby notified that any dissemination, 

distribution, or duplication of this communication by someone 9ther than the intended addressee or its 

. designated agent is strictly prohibited. . 

All tnfOimation is Protected Under U.S. Federal Law 

'-"""--r'--'-' 

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PDU-6655-3 000265



o Urgent 0 For Review 0 Please Comment 0 Please lReply 0 Please RecycOe 

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------.--------------,_._-_.__.------.-------~..---. 

CBR Medical, Inc, - 3115 E. Mission Ave, Spokane, Wa 99202 

'Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Pilone 360-635-6464 Fax 206-418-6659 


entity to whom it is adclressed, and 'may contain information that is privileged', or confidential and 

exempt \rom disclosure under applicable law, You are hereby notified tilat any dissemination, 

distribution. or duplication cif this communication.by someone other than the intended addressee or its 

designated agen~ is strictly prohibited. 

' 


PDU-6655-3 000266

1----------------'---·-·,· , 

1. 

I 

I 

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..!-''''',..,,'''S\ 

f '} STATE OF WASHINGTON 



NAME: 

hereby authorize the use or disclosure of niy health information 


t2.BR ,(14£(1';-(1o..J .;i..Y1 C 

ADDRESS: :3 I /' i:)' e. /Z1'-;s S' -~ ,'/ t!-v'-e. 

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ft'2=-L ,A~,2' G&r./ ;d;: iu.c.

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STATE: OFWASHtNGTON 

DEPARTMENT OF CORRECTfONS 



By state. statute the Washington State Department of Corrections is charged with the' responsibility to supervise some 

offenders after they have been convicted of a felony. The above named patient is currently under supervision by thEi 


behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that. the court or 


'including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has 



725-8700. / 

r 

f 

1. Is this patient under your care [!!"Yes D No . 

2. . Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 


DYes 

a. If the ;answer to question 2.is "Yes", does he/she have anoreXia DYes 

b. If the answer' to question 2a is "Yes": does he/she have weight foss DYes 





DYes 

DYes 

b. . Ifthe answer to question 3a is 'Yes", please describe what those treatments were (medication, dose, 

duration): 

\2fJo 

k31'iIo 

!d1fo 

. r:a-No 

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c. What is the planned s

·#t'RFkM~' If Sa/'oJ 


License #: MO 0 0 0 / t:3 / I License type: -..""-A_tft....._p 

_____ ~_ 

Prescriber's Address . 3/1!:£ e .Illas· -;,JQ a 411 of 

3PD10I1"/fl vU Cot 9 9 Z.D 'L . 

Prescriber: please return this form and tile patient's Release of Information to: 



Washington State Department of CorrectiQn~ 

PO Box 41123 

Olympia, WA985D4-2113 

Phone Number 

500· 5'7{) .. ;J-CJ" 8'" fa 

£'Ot.7 -,lLf lJ. - Jio Z '-/ 



(check one) lOis 0 is not . 



'Instructions to DOC Physician: 



1. . Email your finding above to the Assistant Secretary for Community Corrections 

2. File this form and the accompanying Release of Information in Uberty as a Community Corrections Health Record .. 

Date 

, 

j 

I 

------~--------.-.-.---.-------..:...-.--- ',--- 

, . 

State law (RCW 70.02: RCW 70,24.1 05; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibrt 

disclosure of this Information without the specific written consent of the person to whom it pertains, or as otherwise . 

permitted by law. . 

oqc 14-053 (Rev. 7/31/08) 

DOC 380.:200 

PDU-6655-3 000269



P,O Box 41100' Olympia, Washington 98504-1 lOa 

February 20,2009' 

Edmonds, WA 98026 ' 

DearMr,_ 

Your Medicinal Use of Marijuana request was received on January 23,2009. Upon review by the 

Depai1:ment of Corrections', Health Services physician, your request has been denied. . 

. ., 

You may appeal this decision by sending your written request within 15 business days' of this letter, 

which is onor before March 16,2009. Please send your 'request to the address below: 

i 

I 



Department of COl1'ections 

P.O. Box 41126 

Olympia, WA 98504-1126 


Appeals that do not contain new information wili be denied. You will receive a response to your 


SinCerel~ ,a "A- _ ,- 

~~~~ 



KD:md 

--- --oc:--' -'Ri"chard" K:"ellU\5';CmllItlUntty-Comrctlorrs-S'up-eIV'is"O't-- 

Richard H~mmunity Corrections Officer 

Field File __ 

Physician's Office: , 


CBRMedical 

3115 E. Mission Ave, 


..._.__..__ .....------.----.-~.-_.--.--- _.: ... 

" Working Together for SAPECommunitfes", 

:0 kcycled p.:pcr 

PDU-6655-3 000270

.I..F .... ' .. ' .. ,.~ 

OFFENt:ER 1.0. DATA: 

~ ~i' STATEOFWASHINGTON 

~ DEPARTMENT OF CORRECTIONS 

AUTHORIZATION FOR DISCLOSI,JRE 

. c.B R /V/ 


organization is authorized to make' the di~closure: 

(!{"'/r" to & r .;in C 

NAME: 

ADDRESS: 

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C, H/..:s S,°e> ,1 /tv'e,. 

.

'. : .; ..... '.: ~ ~.;'~". 

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___ I!Lh,e..fiUeclo.utby...Pxes:c.dber.::-----,---------_-------------------- 






the Department of Corrections will impose a condition of supervision that the offender not use, or pQssess illicit drugs, ' 

'including marijuana; This offender has claimed that they have a condition for which the medicinal use of marijuana has 


'assistance, If you have questions please feel free to personally contact the M~dica{ Director' of the Department at (360) 

725-8700. ~ 

. 1. Is this patient under your care ['Yes 0 No 

, 2. Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 

Immunodef~ciency Syndrome (AIDS) , 

a. 

b. 

If the answer to question 2 is "Yes", does helshe have anorexia 

If the answer to question2a is "Yes", does he/she have weight loss 

DYes 

DYes 

DYes 

G.:I-No 

3. 



0 Yes' 

a. If the answer to question 3 is "Yes", has the patient failed to respond to cOl"lVentional 0 Yes 


b, If the answer to question 3a is "Yes", please describe what those tl'eatments were (medication, dose, 

duration): . 


4. 

a. 

. . 

If you answered "No" to items 2 & 3 above, what,is the reaso~ you are r:S-0mmending m.edicinal use of 

marijuana 1:"-ffl-~h..-~ V-

--.:1{ 



I 

I 

License #: fl1.0 () 0 () / r 3 ) / License type: _'-r/"-'A'.,_v.!.-!_._/_~ _____-:::-~__ 

Prescriber's Address -:3 J/ t.i e .J2/; ~'S. :') j'e; /] .4 ~/f Phone Number Sly":;· 5.'!) . .1-t 8" 

3f/5h-RJI'7..P lu'

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P.o. Box 411 00· Olympia, Washington 98504-1100 

April 29, 2009 

..... _~~ew.ic~ '!fA .~9:337.. 

Dear Mr._ 

I received your request to appeal the denial· ofyotU" initial Medicinal Use of Marijuana 


In the interest of public safety and protection of the commuriity atlarge, I find your request for 

Medicinal Use of Marijuana, w1ll1e under the supervision of the Department of Corrections, is 

denied. . 

I would encourage you to continue to program in a positive manner, following the direction of 

your assigned CCO and your conditions of supervision. 

Karen Dairiels, Assistant Secretary 

CommunitY Corrections Division 

KD:md 

cc: 

Michelle Ballard, Community Corrections· Supervisor 

Katti Foltz, Community Corrections Officer 

Field File __ 

______ --"-P.=..;hysician's""Of:fiCe': 


-.... -:- ., .. -............. -_. --... :-··-Hemp~&-Can:n:abisFotindatiijif····:···-··-··-··-· .......... -.... -_ .. - ---. 

. 1813 130 th Ave. NE, Ste. 210 

BelleVue, WA 98005 

o ",cycled P"JlC' 


PDU-6655-3 000274

OlJ/25120l111 15:49 FAX 253 473 9667 Excel Business Sys"tems 141 004/004 

prcii6E!t'$ Nama (Print) 

/-c9l-;!aO; 

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l.icense#: WA OCD[(oi gO LIcense type: 

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Prescriber's Addressd/.3 t0M· ArE .1/£ 

. -z;{a/dti£ \/ZPf ' 

Prescriber: .please return tfuS'TO'rin anc!'tlle patient's Release of Information to: 

Medical· Director 


Phone Number 

/ 

To • e filled out by DOC Physician: . 

[ have reviewed this ve~lfication fO~J~d that I.lse 0(J;dical marijuana by this patient 

(check one) I D is 

IJd'1s not 

consistent with DOC Policy. . !/VA,.., 1 .. // 

•• CURn III". l/l(/l]tI~ 

-l=P.h~~~i~oia~n~~~~~,g~~~w~re~------------------- 

PhysiCi

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"&-J-tiAC{{ }t'cz i



P.O. Box 41100. Olympia, Washington 98504-'100 

April 29, 2009 

. Puyallup, WA 98373 

Dear Mr._ 

I received your request to appeal the denial of your initial Medicinal t)se of Marijuana 

V erification~ . 

In the interest of public safety and protection of the community at large, I find your request for 

Medicinal Use of Marijuana, while under the supervision of the Department of Corrections, is 

. denied. 

I would encourage you to continue to program in a positive man:tJ.er, folloWing tJ:1e direction of 

your assigned CCO and your conditions of supervision. . 


CommUnity Corrections Division 

KD:md 

cc: Carole Rigney, COrrllnunity Corrections Supervisor 

S!even !3u~rnmunity Corrections Officer' 

----------~~lcld-~u~~.----~.--~.----------~--------------~~~------------- 


. Attn: Melissa Leggee 

. CBR Medical, Inc. 

3115 E. Missi9nAve. 

Spokane, W A . 99202 

" Working Together forBAFE CommuniUes" 

PDU-6655-3 000277

.. 

Fax 



I 

, 


To: MONICA DISTEFANO From: Mefissa@cbrmedical.com 

Fax: 360-586-0252 Date: 04f10/2009 

Phone: 360-725-8796 Fages: 

_~_e:___ 111111111~ __________ ~ ______ D_O __ 

C~~-_A_PP_EA 

__ L~ ______ 

tJ Urge.nt o For Review :0 .Please Commen~ 0 Please Reply 0 Please Recy'cle 

! , 

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, 

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.Monica; 

Enclosed is the Appeal for the Medicinal Use of Marijuana for 

sincerely appreciated the time and effort that you personally take iii hal~dlina 


r 

I haJe also enclosed"medical records and. his authorization from Dr. Mohammad'H. 

Said and fyom Dr. Antoine Jlhnson.· . 

Again thanks so much for your time and efforts. They truiy ar~ appreciated. 

Sincerely, 

~ U . ./~ LJ" 

-;@fi..~q ;~~. 

Melissa Legsee 

509·570-2886 


Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509'3-40-2710 

Tri-Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360·635-6464 Fax 206-418·6659 . 

CONFIDENTIALITY NOTICE: This communication is intendeq for the sole Lise of the individual and 


exempt from disclosure under applicable law. You are hereby notified that an'y. dissemination, 



Allinfonnation is Protected Under U.S. Federal Law 

PDU-6655-3 000278

I 

" 

IFax· 

CBR M~difcal,. Inc 



o Urgent o For Review 0 Please Comment 0 PIQasli~ Reply 0 Please Recycle 

I i 

i 

I 

! i 

I 

I ; 

'Comments: 

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f 

GSRMedical, Inc. ~ 3115 E. Mission Ave, Spokane, Wa 99202 . 

Seattle Phone 206~774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri-Cities Phone 509416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALllY NOTICE: This communication is intended for the sole use of the individual and 

entity' to wl!om It is addressEld' and may' contain informatiol1 that is privileged, or confidential and 


distribution, or duplicati~)O of this communication by' someone other than the intended addressee or its . 


All infomnation is Protected Under U.$. Federal Law 

PDU~6655-3 000279

J. 

I 


, . 


.- 



Pali 

I' 

To be fiUed out by Prescriber: 

1--------J-1._~~~9.---LIIiiaI:---. ---J 


By state statute the Washir.1gtcin State Department of Corrictions i$ .c.harged with tne reSporjsib!11W to supervise some 

offenders after they have been convicted of a felony. The above named patient is c.l,lrrently ·unde-i· supervision by the· 

Department. Supervision is designed to help the offender avoid those environments or situations 'that lead to their criminal 

behavior. Often illicit drug use is a .contributing factor in an indiv(dual's crimirialitY:··Accordingly its usual that the court or 


including marijuana. This offel1der has claimed that they have a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the legitiinacy- of their ctaim. Thank you in advance for your 

assistance. If you have questions. please feel free to personally contact the Medical Director of the Dezartme at (~6.0) 

725-8700. .' 

" . 

1. Is this patient under your care' es '0 No 

2. 

3. 

5. 

Are you recommending medical marijuana for his patient due to a diagnosIs of Acquired 


a. If the answer to question 2 is "Yes', does he/she have anorexia 


Are you recommending medica! marijuana for this patient due to nausea and vomiting 


a: If the answer to question 3 is ''Yes'', has the patient failed to respond to conventional 


. .: 

DYes 

DYes 

DYes 

DYes 

.~ 

~. 

~~ 

DYes· ~ 

b. If the a.nswer: to question 3a is 'Yes", please descrIbe what those treatments were (medication, dose, 

duration): \. / 

c. 

 

t,L V . 

What is the planned schedule of chemotherapy. I , 

t 

If yo~ .answered ")'10' to i\ems 2 & 3, above, what is the reason you ar~ recommending medicinal use of 

marijuana akv'o~, ~ p aV-J.....l tv' ~\..L.rc-e=-./ 4JI /fJSS .~ . . 

a. Please provide evidence publl~hed in a peer-reviewed scientific publication to sup ort th edi~lnal use of 

: m'arijuaha"fcfnhis purpose .... rfJie:.": . !>*-.J.





I, Dr: Mohammad H. Said , am a physician licensed in the State of Washington 


RCW 69.51A010. . . . 

·1 have advised the above named patient about the potential risks and benefits of the medical use 

of marijuana. I 'have 'assessed the above named patient's medical history and medical condition. 

It is my medical opiniori that the potential benefits of tI]~ medical use of marijuana may outweigh 

the health risks for this patient. .... . .. 

Physician Name: ~_'D::::.r:.:. .:.::M.:.::o~h=a!..!.m!!..!mc!.::a:.::d:..!H..!.:.:..!S::.::a:.::id::...-__ WA License Number:, __.:.:M:.:.:D~0:..:0:..:0..:.1.:.83=-1.:...;1_ 

Ph ySlclan 

•. S· , fA.A. /-1. S ~f 

Ignature: _,--..£.f_ -_... ---:~______ Date: _-'-. ~02:::.;/2==2::..:/2::..:0:..::;O,;:.9 __.--:. 

This re~ommendation expires on: 02/22/2010 

Risks and banaf(ts of medical marijuana 

Under Washington law, the lise of medical marijuana is now permissible for some patients 

with terminal or debilitating illnesses. Tlie law regulating this (RCW 69.51 A) allows physicians 

to advise patients about the risks and benefits 'of the medical use of marijuana. 



marijuana is safe or effectjve arid"~ome providers' feel that it is 'a dangerous drug. 

According totO$:! Wa$hihgti.:m State law the benefits of medical marijl,.lana may include 

treating nausea ancfvoniiting fr'Om chemotherapy, AIDS wasting syndrome, severe mus~le 

spasms from multiple sclerosis or other spasticity disorders, glaucoma, am:,1 some types of 

intractable pain: , 

Some of the risks of medical marijuana may include possible long-term effects of the brafn in 



dependence. 

I 

"; 

I 

I ! 


As this patient's ;'60 Day Supply", as,'stipulated ,by RCW 69.51A.040 (3)(b) and 

------WAC246-7-5-Q.:1.Q,this-Qualify.ir:Jg-l2atier.lt-car.l-t:6aSor:lably..expect,.to_ba~e..in...their.Eoses.sioJLao.d'__ ~ __ i--_ 

Need a total of no more than 24 Ounces of "Useable Marijuana" and no, more than 15 Plants. 


. Administrative Office 


, 

1· 

1 

I 

[ 

I 

Spokane: 509-242~624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418-6659 

EMERGENCY OR LAW ENFORCEME;NT ONLY 

CALL 509-570-2886 OR 509-570-6943 

; 

PDU-6655-3 000281




March 26, 2009 

Your Medicinal Use of Marijuana request was received on March 4,2009. Upon review by the 

Department of Corrections' Health Sl'lrvices physician, your request has been denied. 

You may appeal this decision by' sending, your written request within 15 business days, on or before 

April!7, 2009.' Please send your request to the address below: 

' 

Karen Daniels, Assistan~ Secretary 



P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide ,additional information that was not included with your original request. 


appeal request within 30 days of receipt 


COll1l1unity Corrections Division 

KD:md 

cc: Carole Rigney, Community Corrections Supervi'sor 

Steven Burriss, Community Corrections Officer 

Field File 




3115 E. MIssion Ave. 

, Spokane, WA 99202. , 


0. recycled paper 

PDU-6655-3 000282

----------· 


From: 

Sent: 

To: 

Cc: 

Subject: 


Friday, March 06, 2009 9:10AM 

Daniels, Karen R. (DOC); Distefano, Monica J. (DOC) 

Hammond, G. 

MM Requests 

. The follpwing requests for authorization for use of medical marijuana do not meet criteria for medical necessity: 

Huebner, Richard S. 922671 

Lewis, Michael 810530 

Schossow, Alex 325303 

Stevens, Mqtthew 322837 

Waggoner, Michael J. 956:468 

1 

PDU-6655-3 000283

03/04/2009 14:18 2064186659 

CBR MEDICAL 

PAGE 01 

I Fax 

CBR Medical, inc 

3115 E. Mission AVe 


C! Urgent 0 For Review D Ple~se Comment 0 Please RGply 0 Please Racy!;ie 

. -Comments: 

C8R Medical, Inc. - 311$ E. Mission Ave, Spokane, Wa 99202 . 

Seattle Phone 206.774-6493 Fax 206-418-6659 Spokane Phone 509·242·8624 Fax 509-340·2710 

Tn-Cities Phone 509-416-2267 Fax 509...s40·271 Q Vancouver Phone 36tJ .. 635·6464 Fax 206--416-6659 

CONFtDENrlAUTY NOTICE: This communication is intended for the· sole use of the individual and' 

entity to whom It is addresse.d. and may contain informatiori that is pl;VUeg~7 or confldenffal ~md 


. distribution, or duplication of this communiCation by someone other than the intended addressee or its 

designated ",gentls strictly prohlbit~d. . '. . . 

'AlIlnfort'l1ation is Protected UI,der U.S. Federal Law 

PDU-6655-3 000284

I 

J 63/64/2669 14:18 

'1-'- --- 

'" 

2654185559 . 

CBR MEDICAL 

PAGE' 62 

STATE OF. WASHINGTON 

DEPARTMENT OF CORRl'!C'l'IONS 


TION 

Ol'~ENOF.R 1.0. OA'I'A: 

hereby authorl%e the use or disclosure of my health Information 

~rn"'lii.,.

STATEOFWASHINGTON . 


P.O. Box 41100 • Olympia, Washington 98504-1100 

April 29, 2009 

Chewelah, VV A 99109 

Dear Ms._ 

I re:ceived your request"to appeal the denial of your initial Medicinal Use of Marijuana 

. Verification. . 

In the interest of public safety and protection of the community at large, I find·your request for 

Medicinal Use of Marijuana, while under the supervision of the Department of Corrections, is 

denied. . . 

I would encourage you to continue to program in a positive manner, following the direction of 

yoUr assigned CCO and your conditions of supervision.· . . 

Sincerely 



KD:md 

cc: RobeD Bro~mmunity Cqrrections Officer 

Field File ___ . 


____-----=Attn:.....Melissa..Legge.e

Fax 

III 

CBR Medicai, Inc 



To: MONICA DISTEFANO From: Melissa(alcbrmedical.com 

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Fax: 360-586-0252 Date: 0411012009 

Phone: 360-725-8796 Pages: 

_R_e: __ ~I1111111111~ ____ ~ __ ~~ ______ ~D~O~C~i~~~-~A~P~P~EA~L~ ______ ___ 

o Urgent o For Review o Please Comment 0 Please Reply o Please Recycle 

Monica, 

Enclosed is the Appeal for the Medicinal Use of Marijuana for We . 

sincerely appreciate the time and effort that you personally take in handling 


I have also enclosed nedical records and authoriZation from Dr. Mohammad H. 

Said and from Dr. Antoine Johnson. Additionally I have' added more information on the 

conditions for which_suffers. 

Again thanks so much for your time and efforts. They truly are appreciated. 

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Sincerely, 


509·570-2886 

CBR Medical, Inc .• 3115 E, Mission Ave .. Spokan~, Wa 99202 

Seattle P~one 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri~Cities Phone 509-416-2267 Fax 509-340-2710' Vancouver Phone 360-635-6464 Fax 206-418-6659 

CONFIDENTIALITY NOTICE: This communication is intended for the sale Lise of the individual and 



distribution, or duplication of this commlJnication by someone other than the intended addressee or its - 



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PDU-6655-3 000287

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o Urgent 0 For Review 

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C8R Medical, Inc. - 3115 E. Mission Ave, Spol

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( ') STATE OF WASHINGTON 

DEPARTMENT OF CORReCTIONS 

Medicinal Us'e of Marijuana Verification 


OFFoNCER 1.0. DATA: 



offenders after they have been convicted of a felony. ,The above named patient is currently under supervision by the 

Department Supervision is designed to help the offender avoid those environments or situations that lead to their crimina! 

behavior. Often illicit drug,use is a contributing factor in an individual's criminality. Accordingly ifs usual that the court or 

the Department of Corrections will impose a condition of sUpervision that the offender not use, or possess illicit drugs, 

including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has' 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your, 

assistance. If you rave questions please feel free to personally contact the Medical Director of the Department at (360) 

72.5-8700. 

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1. Is this patient under your care rn1'es DNo 

2. 

Are you recommending'medical marijuana for his patient due to a diagnosis of Acquired 


a. If the answer to question 2 is ·Yes", does he/she have anorexia 

b. , If the answer to question 2a is "Yes", does he/she hav~ weight loss 

Dyes 

DYes 

DYes 

3. 

Are you recommending medical marijuana for this patient due to nausea af1d vomiting 




DYes 

DYes 


duration): 

4. 

c. What is the planned schedule of Che7therapy 

, " pl. r1- 

a. 

If you answered UNo" to items 2 ~ 3 ab~ve,.what is the rea3~ are,recomT.e~i~g medicinal use of 

marijuana C I... "-011 .. t. P C!t. I\...._ S. ~ ... \ S !.A-VB .A. ( 

M v.... ~!.e.. ~ f"'-~\.V'-I tJ~k d.. Yi e:-.-~"- 

Please provide e~iden~e PUb~~ ~ a peer-reviewed scientific publication to support the medicinal use of 

marijuana for this purpose ~ 

0' ,N...r 

~--------------,-----,----O~~---Y~~~------Y-------------------------------~~ 

5. 

. , 

6. 

While on community supervision ("parole") the Department of Corrections o~ly aut~oriz~s t~e 

'use of the oral synthetic formulation of marijuana. If the Department ~uthonzes ~hls patient s 

use of medical marijuana, will you 'be prescribing only the oral synthetic formulation 

The patient's accompanying Release of Information authorize~ you to provide the' , 

Department with current and future' information rel~ted to this Issue, Do you agree tq notify 

the Department's Medical Director of any changes In your'answers above 

O.Yes 

0 Yes 

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DOC 360.;200 

PDU-6655-3 000289



PATIENT NAME: ___ _ DATE OF BIRTH: _1970 

I, Dr. Mohammad H. Said , am a p~ysician licensed in the State of Washington 


RCW,69.51A.010. 

I have ad~ised the above named patient about the potential risks arid benefits of the medical use 

of marijuana. I have assessed the above namecl patient's medical history and wedical.condition. 

It is my medical opinion that the potential benefIts of the medical use of marijuana may outweigh 

the health risks Jr this patient. 

Physician Name: _--,O::.:.:..r. ~M.:.;:o:.:..:h=a:.:.;m,-,-,m..:::a:.=d,-,-H~ ...::S~a:::.:id=--__ WA License .. Number: ....,--_·.'-M_D_O_OO_1.'-8_3_1_1 


This recommendation expires o.n: 02/01/2010 

f1 < JI. cfq :J:ate:__ 

O=2/..;.,ci1.;.;.;/2",,0-,,-09,-.:-::--_~ 

/ . . .: ,.. 

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, 

Risks and benefits of medical marijuana· 

, Under Washington raw, the use of medical marijuana is now permissible fbr some patients 

with terminal or debilitating illnesses. The law regulating this (RCW 69.51A) "allows physicians 

to ~dvise ·patients about the risks and benefits of the medical use of marijuana. 

The medical and scientific eviden·ce supporting the u~e of medicaIrnarijuana remains 

controversial in the medical community. Not all health care providers be.Heve .. that medical 

marijuana is safe or effective and sOme providers feel that it is a dangerous drug. . . 

According to the Washington State law the benefits of medicai marijuana may include 

treating nausea and vomiting ·from chemotherapy, AIDS wasting syndrome, severe niuscle 

spasms from multiple. sclerosis or other spasticity disorders, glaucoma, arid some types of 


Sorne of the risks of medicpl marijuana may include possible long-t~rm effects of the .brain in 

the areas of memory, cooidination and cognition; impairment-of the ability to drive or operate 


. dependenc.e: . 


As this patienfs "60 Day Supply", as stipulated by RCW 69.51A.040 (3)(b) and 

-'-_____ WAC24.6::Z.5=-OiQ,jhis_Quaf.ifY-iog-'~atle.oLc.anJ:e.as.P.oab.ly-el

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STATE OF WASHINGTON . 


P.O. 60)(41100' Olympia, Washil1giol1 98504-1100 

March 26, 2009 

Ms.". 

Dear 




April 17, 2009. Please send your request to' the address below: . 




P.O. Box 41126 

Qlympi; WA 98504-1126 

Your request must provide additional information that was not included with your original request . 

. Appeals that do not contain new in:formation will be denied. You will receive a response to your . 

. appeal request WIthin 30 days of receipt. 

!fIT. . 

"q) recycled paper 



KD:md 

cc: Robert Bromps, Cornnl1:lI1ity Corrections Officer 

Field File -••• 



CBR Medical, Inc .. 




PDU-6655':3 000291

---_._.-» 

" 


From: 

.. Johnson. Deborah A. (DOC) on behalf of Hammond. G. Steven (DOC) 

Sent: 

Monday, February 23, 2009 4:37 PM . .. 

To: Distefano, Monica J. (DOC); Daniels, Karen R. (DOC) .. 

Cc: 

_ ammond G. DOC). 

Subject: .. 

MM Request 

_request for authoriz~tion for use of medical marijuana does not meet criteria for medical necessity. 

1 

PDU-6655-3 000292

1-----.. ·· -"-'--"-' ....... .. 

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From: ruel \:")w @ (i 1::£ 

Pages: 

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CBR Medical, Inc. - .3115 E. Mission Ave, Spokane, Wa 99202 

Seattle Phone 206-774·6493 Fax 206·41 6-6699. Spokane Phone 509-242·8624 Fax 509-340-2710 

Tri-Clties Phone 509-416·22.67 Fax 509·340-2.710 V:;;ncouver Phone 360-635-6464 Fax 206-418.6659 

CONFIDENTIALITY NOT1C~: This communication is intended for the sale use of the' individual and 

entfty to whom it is. addressed, and may contain' information that is' pliViIeged, or confidential and 


distribution, Dr duplication of this communication by someone other I.han the intended addressee. or its 

designated agent is strictly prohibited..' . . 

AlIlnformatiol1 i$ Protected Under u.s. Federal Law 

PDU-6655-3 000293

STATE O~ WASHItIIGTON 


AUTHORIZATION FOR DJSCLOSURE 

OF 

OI'l'EN= 1,0, OATA; 

I, hereby authome the use or disclosure of my health information 

or organization is'authorized to make the disClosure: 

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SpD ton t1 I l

... _._._-----.-... _-----_ ..... _-_._-_._-- 

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OFFENDEllI.D. DATA' 

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STATEOFWASHINGTON 

......, DEPARTMENT OF. CORREC110NS 





offenders after they have been convicted of a felony. The above named patlent is currently under supervision by the 

Department. Supervision is designed to help the offender. avoid t~ose environments or situations that lead to the.ir criminal 

·behavior. Often illicit drug use is a oontributing factor in an individual's crIminalitY. Aocordingly it's usual that the court or 

the Department of Corrections will impose a condttion of supervision that the offender !lot use, or possess illicit drugs, 

including marijuana. This offender has 'claimed that they have a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you in OIdvance for your 

aSSistance. If you have questions please feel free to personally contact the Medical. Director of the Department at (360) 

725~8700. 

1. Is this patient unqer your care 



a. If the answer to question 2 is "Yes·, does helshe have anorexia 

b. 'If the answer to que~tion' 2a is "Yes·, does helshe have weight loss 

~es 

~Yes 

DYes 

DYes 

ONo 

E:rNo 

r:rt'io 

[31iIo 

3. Are you recommending medical marijuana for this patient due to nausea and vomiting 0 Yes B'folo 


a. If the answer to question 3 is "Yes·, has the patient failed to respond to conventional 0 Yes ~o· 

. antiemetic treatments . . 

....•. _ •.•. c.: ....... R, ..... JfJbiLansw~!JQ g.l!~!Qt!.Ja is 'Y§!f:t.Qlea~e d~g!~.~I}§Uh.~~ .~~~!!!)~~.~~@JI!l~C.~~~.!..~se, .....___ .. ,_"._" ...._... 

duration): . r.i I fr . 

4. 

. c. 

a. 

. . 

What is the planned schedule of che.7therapy 

rJ y,J.;-' 

If you answered "No" to items 2 .& 3 above, what is thirea:r~u are. recomm~i~g medicinal use of 

marijuana C l.. ('"()h ; t. P Co. i k.. - S "'~ . ~ s v.-V"3~,{ ( 

Mv.... '3 /...e.. £:. [p60.r._; tJ~ r;:,. ~ r~ _I!..

...... ,u, .... 1'IL..u.L.\..IHL... 

Efp he. M.~L I{, ,s&: j 

Prl!scribe~s N;me (Print) Preserlber's Signature . 

License #: ..jM D 0 0 0 t 3 I I License type: -=A--'-=v"--_____ ---, ___ _ 

Prescriber's Address :3 f { S- E. 1k1" 5-;',' D () 4,; f' . Phone Number 

~. {::::o "Vl J. u.) "I.. q '7 2-0 z.. . 

Prescriher: please rewrh this form and the patienfs Release of Infonnation to: 


Health Services Drvrsion 


PO Box41123 

Olympia, WA 98504-2113 

5])1'- 5"7 Q -;;. ~~.b 

310C -~ 'I ;. - rg- (p ~ 2.. 

. I 

To be filled oot by DOC Physician: .. 

a· 

I have reviewed this verification form and find that use of medical marijuana by ihis pati~nt 

(check one) lOis [1]15 not 

".[Rr . In\. 

1 consistent with DOC Policy. ! 

'Physioian's Neme (Print) . 

F>l1ysfolan's Sig."liIture 

au~ 

,Instructions·to DOC Physician: 


1. Email your finding above to the Assistant. Secretary for Community Cqrrectlons . 

2. File this form and the aocompanYing Release of Information in Liberty ;;lS a Community Corrections Health Record. 

State law (RCW 70.02; RCW 70.24.105; RCW 71.06.390) and/or rGderal regulatloll$ (42. CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infonnatiQn without the specific written (:onsent of the per.son to wl10m it pertains, or as otherwIse 



PDU-6655-3 000296

.. ' .. , -~ ...... 

, ........._...... . 

Documentation of Medical Authoiization to Possess Marijuana 


! . 

PATIENT NAME: _____ ==-__ .:......,- DATE OF BIRTH: _1970 

1, Dr. Mohammad H. Said , am g physician licensed iii tne State of Washington 

and I am treating the above patient for a terminal illness or a debilitating condition as drafined by 

RCW 69.51A.010. 

I have advised the above named p'~tient about the potential risks and benefits of the medical use 

of marijuana. 1 have assessed the above named patfent'!:>. medical history and medical condition. 

It is my medical opinion that the potential benefIts of the, medical use of marijuana may outweigh 


Physician Name: _-=D:..:,:r.:...:,M;.:.;o;;.;,.h;,;;;:8.;,:;m:,;.:.l1lC1=d.;.,.H:.:.... :::..Sa=.:i.:;:.d __ WA license Number._--.;.M..;,.D_O_O_O_18_3_11_ 

PhySician Signature: 

This recomrhendation expires on; 02101/2010 

It ' #. db. J:ff>: _--=O.=:2/.::...01.::..:/2;;.,;:;O~09~ __ 

i 

\ 

I 

Risks end benefits of medical marijuana 

Under Washington law, the use of medical marijuana is: now permissible for some patier'lts 

with'tenninal or debmtating illnesses. The law regulating this (RCW 69.51A) allows phy.sicians 

to advise, patients about the risks and benefits of.the medical use ofmalijuana. 

The medical and scientific evidence supporting the use of medical malijuana.r.emains 

controversial in the medical community. Not all health carra providers believe that medical 


According to the Washington State law thebenet'its of medical. marijuana may incru.de 

treating' nausea and vomiting frcim chemotherapY,AIDS wasting syndrome, severe muscle 

~p'asms from multlple sclerosis 01' other spasticity disorders, glaucoma, and sOme types of 

intractable pain.' , . 

Some of the risks of medical marijuana may include possible long-term effects of the brain in 

the areas of memory, coordinatiotj and cognition; imp'airment of the ability to drive or opsrate 

heavy machinery; respiratory damage; possible lung cancer; and physical or psycholo'gical 

dependence. ' ' , ' 


·AS this patient's "60 Day Supply", as stipulated by RCW 69.51A.040 (3)(b) end , 

WAC 246-70-010, this Qualifying Patient can reasonably expect to have in their Posessfon and 

----Need-a'iota·l-otno-rhore tf@124"Ounces Of "Useable Marijuan,a n and no more than 15 Plants. ' 


. Administrative Office 


Spokane: 509-242-8624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418-6659 


CALL 509-570-2886 OR 509-570-6943 

PDU-6655-3 000297 

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-- ... --.. _-.- --.---.... 

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tiCn of ·M«llcat AuthOrizatiOn to Possess Marif lJana 

~ Medical Purposes In Washington State . 

PA"!1ENT NAME: __ - 

----- 


~ndatJon 

~ this patient's "SO day auppIY', as SIipufated by ptNf ~.51A(2)(b)" t ~ 24 ~ 

of dried, cured marijuana and sa many pants as·the patient feels ~ 1(1 malmtn this -eo 

_--:-____ daysuw'1'. 

.~-~~~~~-----~---- 

PDU-6655-3 000298


DEPARTMENT OF CORRECTIOi'iS 

P.o. Box 41100· Olympia, Washington 98504·1100 

April 29, 2009 

Graham, W A 98338 

. DearMr_ 


VerificatioI.1. . . 

In the interest of public 'safety and protection of the community at large, I find your . 

request for Medicinal Use of Marijuana, while under the' supervision of the Department 

of Corrections, is denied. 

.' 


. direction of your assigned CCO and your conditions of supervision. 

. , , 


Community Corrections Division . 

KD:md . 

cc: 

Suzann Braverman, Community Corrections Supervisor 

David Bingh!iIIl, Community Corrections Officer 

Field File - noc_----:--~ .. ........ ..... . 


__ ~ ________________ ~Th~o~m~a~Q~a~al~d~ ______ ~ __________ ~ __________ ~ __ ~ ________ ~ ____ __ 

1813 l30 th Ave. NE, Suite#2W 



~ recycled P'lper 

PDU-6655-3 000299

,--_._._._.- ...•.._..._...• , .. 

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DEPARTMENT OF CORRECT1.ONS 

P.o. Box 41126· Olympia, Washington 98504-1126· (360) 72~-8796 

FAX (360) 586-0252 . 


Mr._ 

Dear 

Your Medicinal Use of Marijuana request was received on December 17,2008. Upon review by 

the Department: of Corrections' Health Services physician, your request has been denied. 

You can appeal this decisio~ by sending a written request to me within 15 business days, which 

is on or before Feb~ary i, 2009. Please. send your requestto my attention at the address below: 

J 

I 

I. 




PO Box 41126. 

Olympia, WA 98504-1126 

Your request must provide additional information that was not included with yoUr original 

request. Appeais that dci not contain new inforn:J,ation will be denied. Yau will receive a 

response to your appeal request within 30 days of receipt: . 


I' ____ -..:::C::..:o~mm=um=·IT Corrections Division 

KD:md 

cc: Suzann Braverman, Community Corrections Supervisor 

David BinghaIn~ Corrections Officer 

Fi6ldFile -_ 

PDU-6655-3 000300


From: 

Sent: 

To: 

Subject: 

Braverman,. Suzann E. eDOC) 


Dis~; Bingham, David L. (DOC) 

RE~m request 

Thank you!. 

David- print this and keep' in file and be sure it with discovery packets in the future. 

-suzi 

From: 

Sent: 

To: 

Subject: 

FYI 



Bingham, David L fDOC)i Braverman, Suzann E CDOC) 

FW: mm request . 

(I apologize for the delay in forwarding this - weather issues ... ) 


Executive Secretary to . 



7345 Underson Way SW . . 


(360)" 725-8796 


From: 

Sent: 

.To: 

Subject: 


Wednesday, December 17, 2008 9:07 AM 

request 

Mr._request for medical marijuana is· not consistent with DOC policy and therefore denied. 





POB41123· 


360-725-8700 

1 

PDU-6655-3 000301

I ---~ 

.......-.- .. ._-_. 

-.~~- 

__ ... _.-... __ ._ .. _----_ ... _-- 

i 2008-12-16 ;7:17 3605869060 P 1/3 

THCF MEDICAL CLINICS 

1813 1301h Alenue NE. SuHe #21 0 


Phone: (425) 869-6186 

. FAX; (425)·869-6378 

W'J.w, thc_foundation.om 

. . . . Medical Authorization to possess 

Documentation of . poses in WasbiBgton State 

Marijuana for MedIcal urp 

. Date of ". I am treating the above n~ed 

a hysician licensed in the ~~te ofW~shi~o~CW 69.51A.OI0.lhav~ adVlsed the 

1, Thomas O!"l~d: am. P or a debilitating condition as de_1,!l m. of marijuana, I haVe assessed 

patient for a temuna1111ness otenti.a1 risks and benefits of the me~cal use d' al opinion that the potential 

th 

b amed patient about e P di al condition It 18 my me Ie 

~::~:ve named patient's mediCal. ~istory ~~~:~e~ outweigh the health risks for this patient. . 

benefits of the medicaillsc of manJua: ~-:"J...!()~~~lt/~~~~~ftJ-1.ctb~·!.w~. __' _-- 

Signature of Physician: ~ ~.L , 

Thomas O. Or¥ald, M.D. 

WA # MD 00016180 

10 .JuJv 2008 Expiration date::_-.! lOUJ u!:!!1f.ty.:.2~OO~9:..-' --- 

Today's date:_.....1~.l.!_ :!!.!.-.!!.:;!.~---- 

..... : 

Risks and benefits of medical marijuana: 

Under Washington state law, the use of medical marijuana is now penrussible for so~~ patients ~th 

terminal or debilitating illnelises. The lAW regulAting this (R,CW 69,51 A) allows physlclans to adVIse 

patients about the risks and benefits of the medical use of marijuana. 

. . 'al' 

The medical and scIentific e-vidence supporting the use of medical ma..-ly..!ana remams controversl in· 

the medical community. Not all health care providers believe that medical marijuana is safe or 

effective and some providers feel that it is a dangerous drug. 

According to the Washington state law the benefits of medical marijuana may include treating nausea 

and vOIIlltirig from chemotherapy; AIDS wastmg synarome; severe muscle spasms from mwti.-p..-:le------~ 

sclerosis or other spasticity disorders; glaucoma; and some types of intractable pain. 

Some of the risks of medical marijuana may include possible long-term effects of the brain in the 

areas of memory. coordination and cognition; impairment of the ability to drive or operate heavy 

machinery; re~piratory damage; possible lung cancer; and physical or.psychological dependence. 

Text on this form pr~vided by the Washington State Medical Association. 

PDU-6655-3 000302

2008-12-16 17: 17 ••••• > 360 586 9060 

...... __ ._._-------_._--'----_._------ 

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200B-12-16 17:17 

• • • • 1.1111 tI~1 L;tlao 

., 

..... ..__.-._-_._---_.....-." 

"..._----_ ..--_ .. 

-•............ _.' ...._.:._- 

360 SB6 9060 

P 3/3 

5U5II-ESS SERVrCES ~ 

PAGE eS/El3 

.~ 

Medioal Cireetor 

Helllth SQrvIoet OiviItion 

Washington S~ DepartM~ C! CorToetlorrs 

PO BO.d112S· 

.. Olympia,WA 985"04-2113 

T~ bo til/ad out by DOC PhY81c1an~ 

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. Inltructlone to OOC PhySician: 

.' . 

:Nhen.fOl'lTt la complete: . 

. t. l:JnaJf )IOI,Jr finr:tlnQ above to the Asslaiant Secretary10r ComlTll,Jnity CorreclioM 

S. RIiIlf'lil fom anI! the ~ganying Aolsue oIlnfonnation 10 Liberty. a Community Con'ecfione Health Riootd. 

I 

OOC3S0.200 

.:iOHl 

8L£9698S~j:s 

PDU-6655-3000304

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MORE THA·N MAIL 

17719 Pac.i,fic' Ave So. SpanawaYr' Wa 98387 

Phone# (53)846-93'15 Fax# (253)847-0205 

Nu~ber .of Pages' _ . ";L' . 

. (incl'udes Cover PQge)' . 

-.-'-.. -~.- 

..:-. 

,- 

Phone # ____ ~----.-__ - 

(Please 'include Area Cod~) 

__ 

.. Fax# __ ~~,w;..,.::o~, _----.:;0:;;...;.,:. B~0--:-.---:;;;O-:.:Ql.:.::.....:::.5--.::;;:2--::..--_~_ 

(Please include' Area Code) .. , 

FROM: 

Name: 

---- - - -- - - --- 

. ',.' 

Phone # 

(Please include Area Code) 

I 

I 

Receiver: If there is any problem with this 

. transmission please call1-888-439- 785 

ASAP. . . Our customers do not leave their . 

documents whe~ they le_a:ve.. Thank you 

1:13 39'v'd 

lI'v'W N'v'Hl 3ClO~1 

PDU-6655-3 000305 

913Z13Lv889G 98:131: 51313Z/1:8/89

•••••••• ~ __ ' ••• - - __ ", __ ..... _ ••• _ •••••• M ••••••• , ••••••••••••••• " .... __ •••••••• M .... __ ,. __ •••••••••• _ ••• ' 

r----------- 

To;Departnlcnt of corrections 

Attention: Ms. Sandra Sajawski 

27 Merch, 2099 

I have been following and treating 

a medical conditioll and have 

prescnoed propoxyphene for his pain. 

_ 

During -the time that I have followed hi.ri1, I have found no evidence of cmollic alcohol or 

drug use or abuse. - 

I have ellc10sed a copy ofms most recent urine drug screen. . 

. If you have any further questions or concerns, you may contact me at my pbone number 

beloW. . 

:Respectfully, 

John .P9rter, PA-C. 

. Madig Army Medical Center 

Tacoma, Washington 98431 

(253) 968-0770 . 

'.'. _.. -..... ~"-"""'--"",---"""""""'--'-"-"-' ............. 

__ ._ ....... -_._-;-_ .. 

• 

lI\;IW N\;IHl 3ClOW - S02:0LJ;>8ESZ 9E:0! 600Z/!E/E0 

PDU-6655-3 000306

: 

i 

Mar.26, 2009 

Mrs. Karen Daniels, 

My name 

I am writing this appeal in response to the letter I received on 

March 24, 2009, which denies my use of Medicinal Marijuana as treatment for my existing medical 

conditions. The letter also fails to explain the reason for their findings to which I believe I des~rve an 

explariation because I cannot think of any legitimate reason. The letter states that I can appeal this 

decision onor before Feb'ruary 2, '2009,'but I only received a copy of it at a hearing on the i4 th of March. 

The address, I notice, is incorrect, therefore the probable reason. In addition, my supervising officer 

never informed me of the decision. In the distribution list, they Were appare 

way to furnish me a copy of the decision based on my appeal is via email at 

sent a copy. The best 

In reference to current law (RCW 69.51A.)' the use of prescribed Medicinal Marijuana is lawful in the 

State of Washington to treat my present medical condition. The current medications I have been 

prescribed are Propoxyph.ene65MG, OXycodone 325MG, Prylosec, and Naproxen 500MG by my 

attending physician. 

My physican previously prescribed the medicinal marijua.ria as an alternative to 

avoid the side effects of continual use of the aforementioned drugs and narcotics, stating that the 

benefits are likely to outweigh the health risks often associated with continual drug ingestion. One side 

effects I am currently experiencing is indigestion and heartburn (treated by the prylosec) because the 

lining of my stomach is th!nning. I am also drowsy and have intermittent dizziness. I have no prior 

occurrences of these symptoms in my medical history. I had no prior knowledge that this was even .an 

alternative to all the. medications I am taking. Upon a visit to the physician, she asked if I would consider 

this y~eatment, discussed the benefits and risks and thus I agreed to her treatment plan. If my phYSician, 

a medical professional, recommends and prescribes this treatment plan, coupled with it being within 

the limits of the laws of this state; why am I being denied what is beneficial to my overall"health and well 

being I fail to understand this. Yes, I am currently in community custody, but that does not single me 

out as a person that shoul.d not take advantage of the best medical treatment that can be provided to 

meet a legitimate need .. Having committed a felony offense does not automatically dismiss me from 

the category of h.uman being, yet I sense there is an attempt to prohibit me from acquiring some sense 

of quality of life in the midst of already trying circumstances: This is not a game, but a serious quest for 

. some equality under the law. In the form, DOC 14-053, Medicinal Use of Marijuana Verification, the first 

paragraph states, "Supervision is designed to help the offenqer avoid those environments or situations 

that lead to their criminal behavior." My "criminal behavior" was not influenced by the use of marijuana 

or any otl'ier drug, fl'iey are totatlyunrel-ateetil'ierefm-;liOfe2fso-naoleexpll3ifatic:rrrSUPlfOl'ts-l"i"l1kin-g 

"illicit" drug use as a contributing. factor in my past criminal behavior. Anger and lack of control fueled 

that situation, nothing else. I was sentenced in accordance with the law, served my time in prison, and 

am doing the best I can to complete the remaining requirements under superVision. More than tension 

currently exists between my supervising officer and I for reasons I canno~ fathom. Perhaps they have 

influenced the decision by their recommendations (if applicable) as another way to hinder my progress 

versus assist me. I am only assuming, based on' our relationship, but truly believe there is some merit in 

PDU-6655-3 000307

j 

.j 

I 

that statement, In conclusion, I fail to see the basis for denial of a treatment plan that is beneficial to 

lily health and well 'being. I have enclosed information concerning my current prescription drugs and 

their side effects to consider in review of this appeal. Thank you for your time in feviewing this matter, 

I. 

PDU-6655-3 000308

1------·-· --------- .. - 

., 



.P .0. Box 41100 ~ Olympia;· Washingto·n 98504·1100 

March 26, 2009 

DearMr._· 

Your Medicinal Use of Marijuana reque,st was received on March 3, 2009. Upon review by the 



April 17, 2009. Please send your request to tl:J.e address below:' 

Karen DanielS, Assistant Secretary 

COminunity Corrections Division 

, . Department of Corrections 

P:O. Box 41126 

Olympia,WA 98504-1.126 

Your request must provide additionat information that was not included with your original request. 

, Appeals that d~ not contain new information will be ~enied. _ You ""ill receive a response to your ' 


50 . . 

t.j} ",cycled pop« 

Karen Daniels,Assistant Secretary 

Community Corrections Division , 

KD:md 

, cc: Mac P.eveY, COInmunity Corrections Supervisor 

Marki 

Community Corrections Officer 

Field File 


Alison Roxey 

Roosevelt Clinic· 

4245 RooseveltWayNE 

Seattle, W A 98105 . ' 

t< Working Together for SAFE Communities" 

PDU-6655-3 000309


From: 

Sent: 

To: 

Cc: 

Subject: 


Wednesday, March 04,20094:13 PM . 

'Oi~tefano, Monica J. (DOC); Dani~ls, Karen R. (DOC) 

~OC) 

____ MM Request 

request for authorization for useof medical marijuana does not meet criteria for medical necessity. 

i 

I 

.1 

1 

PDU-6655-3000310

10 ~o~{ors.a,.CJC, 

.I' '\ 

1!f£ STATE OF WASHINGTON 

~ : DEPARTMENT OF CORRECTIONS 


MARy 3 ZOng 

Dept. OT t;orrectlOns 

Health Services 




offenders after they have been convicted of a felony. The above named· patient is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead. to their criminal 

behavior. Often illicit drug use is a contributing· factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Correctior:1s will impose a condition of supervision that the offender riot use, or possess illicit drugs, 




725-8700. . 

1. Is this patient under your care . SIV\C! S I ']..OO~ .:e:r: Yes DNa 


Immunodeficiency Syndrome (AfDS) . . 

)(J, Yes DNo 

a. . If the answer to question 2 is "Yes', does h~/she have anorexia 


gtYes 

DYes 

DNa 

[&No 

3. 

Are you recommending medical marijuana for this pati~nt clue to nausea and vomiting .~ 

associated with cancer chemotherapy- p\. I.-..M. I-Io..d. . c.~'-'~* VCNJ.I.. ~ 

'S\"'C(....~~'-I M. '2-00:- 

a. If the answer to question 3 is "Yes', has the patient failed to respond to conventional 


BYes 

IZl Yes 

DNa 

DNa 

, . 

~ 

i 

I 

b. Ifthe.answer to question 3a is "Yes', please describe what those treatments were (medicatin, dose, .I"f_. IJ.., 

duration): Pht.V\.W" tv\I\. crt7J...l) -: c.A.M ~ d. ~d.b'cY\.. !v\e.-t'Vd..o~d.e ,.... l'LD~(.....'t 

e.11"'M1tA.1.iM _. vW .~{k.ct- (fW ff Mpo)t-, p~t u.J.€.-) . 


':\'~ ~\..e.kA IV\. 2.00~. 

4. If you answered "No' to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuanal "~I.CX\\:1ed.- MV1tt.bl;W1 htcw~ tM"I. cS·~ IMf ~& cUcL kJJ7- 

t..eJ p~ k i-J- IS ~dt (,,~W ~ Or\M.M,~ 

8,.. Please provide evidence published in a peer-reviewed scientific publication to support the medicinal use of 

marijuana for thi~ purpose . . 

-,r L r a; .'r.:/-fijJij.O -;h;-r;;:;;ti r/irJtree4-Vi:mr""A-',,",-}1r.A:I..j.,h·ue.--:---f"r-rrrb"~et-~-B-M=F·!-- 

L.MY/tlvl!wI'dS (Qr CtlYlfypI tJt C- /Y"'""f'L(' ~ . Il..(rt. r vvrv vo ' 0" ~ ICNVV","," .) !-' 

. ... . .J ki ':f-, 20'0 I 

5. While on community supervision ("parole") the Department of Corrections only authorizes the ' 

. use of the oral synthetic formulation of marijuana. If the Department authorizes this patient's El Yes 0 No 


1N.llm·iw1" l~.OOtr !w l!;ILft'eSS=I1JVt 1M. hie p~bJ..ilI1rL dh'C.er httd· oidl hu. u..K tJ6 ~Utu.P.... 

6. The patient's accompanying Release of Information autHorizes you to provide the . 

. Department with current and future inform.ation related to this issue. Do you agree to notify 


I ~ . IWJJ1~ 1tu'c c.4kic...- I·v\' \eJo 200:\.- ·'Pt:LlI'~n 

tAl it l b.L. ~ g u.Q..ah~ 


PDU-6655-3000311 

!&Yes 

V\eJ.U 

flAb 


ONo·


License #: 1.\1--1 S

• 

o 

•• - 

••• 

o Oly:rn,pia, 

roo 

1 



P.O. BClX 41100' Olympia, Washington 98504-11.00 

March 26, 2009 

Eatonville, WA 98328 

DearMr" 

Your Medicinal Use of Marijuana request was received on March 11, 2009 .. Upon' r~view by ¢,e 

Department of Corrections' Health Services physician, your. request has been denied. 

You may appeal this decision by sending your written request within 15 busineSs days, on or before 



COrnlnunity Corrections Division 

Departrrient of Corrections 

P.O. Box 41126 

WA 98504-1126 

Your request must provide additional information that was not included With your original request. 

Appeals that do not contain new information will be denIed. You will receive a response to your 

appeal request Within 30 days of receipt. 


Community Corrections Division .. 

c., .. 

KD:md 

cc: Carole Rigney, Commuriity Corrections Supervisor 

Steven B~mmunity Corrections Officer 

. Field File __ 

. Physician's Office: 

THCF 

1813 l30 th Ave.l':ffi, Ste #210 

Bellevu~ WA 98005 

o recycled paper 

" Working Together fey ~AFE Communities" 

PDU-6655-3000313

------·----··-·-···-· .------ .- 

J 

, i 

j 

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From: 

Sent: 

To: 

Cc: 

Subject: 

_ 


Tuesday, March 17, 2009 4-:36 PM. 



FW: 

MM Request 

request for authorization for use of medical marijuana does not meet criteria for medical necessity. 

1 

PDU-6655-3000314






RECEIVED 

MAR j 1 Z009 

D . 

epr. OT liorrecrions 


'--________, hereby authorize the use or disclosure of my health information 

as described below. The following individual or organization is authorized to make the disclosure: 

NAME: 

ADDRESS: 


. Medical Marijuana use and length of prescription 

Purpose for disclosure: :Compliance with Court Order 

I understand that the information in my health record may include information relating to sexually. transmitted . 

infe9tions. Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also 

include information abouf behavioral or mental health services and treatment for alcohol and drug abuse. 


NAME: 

ADDRESS: 

Department of Correctiuons 

405·W. Stewart Ave., Suite B 

Puyallup, W A. 98371 

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this 




or condition: 1 O;02i2009. (if. left blank, authorization will expire six (6) months from signi~g). 


authorization. I neeq not sign this form in order to assure treatment. I understand that I may inspect or copy the 

information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclo!Sure 

of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal or 

state confidentiality rules. If I have questions about disclosure of my health information, I may contact the 

____ RI:UJJdesignee_oLtheJacility~_Records_Departmentl-Department-of-Corrections 

. 10, "~Og 

Date 

. if form· is not complete) (Patient to complete) 

~~ 

Date of Birth DOC Number . 

Signature of Witness Date . 

Sialdaw (RCW 70.02; RCW 70.24.105; RCW 71.05.390) dnil/or ftderal regulations (42 CFR Part 2; 45 CFRPart /64) prohibit disclosure 

. . of this information without the specific written consent of the person to whom it pertailis, or as otherwise permitted by law. 

DOC 13~035 (0511912008) POL DOC 380.200 DOC 600.020 DOC 640.020 DOC 670.020 LEGAL 

PDU-6655-3000315


STATE OFWASHINGTON 

DEPARTMENT OF .CORRECTIONS 


Birth 




offenders· after they have been convicted of a felony. The above named patient is currently under supervision by the 


behavior. Often illicit drug use is a contributing factor·in an individual's criminality. Accordingly it's usual that the court or 


including marijuana. 'This offender has claimed that they have a condition for which the medicinal use of marijuana has . 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your . 

assistance. If you have questions piease feel free to personally contact the Medical Director of the Department at (360) 

725-8700. .. 


2. . Are you recommending medical marijuana for his patient due to a diagnosis of Acquired 


3. 

a. 

b. 

If the answer to question 2 is ''Yes'', does he/she have anorexia 

If the answer to question 2a is ''Yes'', doe~ he/she have weight loss 


associa,ted with cancer chemotherapy 

DYes 

DYes 

DYes 

DYes 

a. If the answer to question 3 is "'fes", has the patient failed to respond to conventioncil 

DYes 



duration):' . 

DNo 

~o 

DNo 

DNo 

g1Jo 

DNo 

. c. What is the planned schedule of chemotherapy 

4. .If you answeied "No" to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana \ . 

t V\ {O V\. \ L ~fA ~." . 


.marijuana for this purpose 


use of the oral synthetic formulation of marijuana. If the Department authorizes this patienfs 



Department with current and future information related to this issue. Do you agree to'notify 


0 Yes 

DYes 

[ifl10 

~o 

DOC 14-053 (Rev. 7/31/08) DOC 380.200 . 

PDU-6655-3000316

Prescribers Name (Print) 

License #: 

_ ..... 

Prescriber's Signature 

I t rH t. 17. O~~jc..L MOt 111015 a./ 

i)"",. ':"''''.1..:\"",,-,-,,-,V\,--~Sc-=.:.h..l.f.( .... e ..... 

2--L1-0r 

(,:;.::.\!:-..:::.n''''V\J''c. ""U"--_ License type: ______________ _ 

, (3 


Prescriber's Address 1S~ .2~~ .-Z·1-05 Phone Number. l_{) __

1813 Born Avenue NE, Suite'#210 


Phene: (425) 869-6 I 86 . 

FAX: (425) '869-6378 

www.thc-feundatien.erg- 

Documentation of Medical Authorization to Possess 

Marijuana 'for Medical Purposes in Washington State 

I 

I i 

1 

I 

I 

I 

I .. 

Patient Name: 

Date ofBirth:~ 

I, Themas Orvald,am a physician licensed in the State efWashingten. I am treating the abeve named 

patient fer a terminal illness er a debilitating cQnditien as defined in RCW 69.51 A. 0 10. I have advis'ed the 

abeve'named patient about the petential risks and benefits ef the medical use o.f marijuana. I have assessed 

t.he above na.T!1ed patient's medical histery and medical cenditien.It is my medical epinien that the petential 

benefits ef the medical use ef marijuana weuld likely eutweigh the health risks fer this patient 

Signature Of'PhYSician:' ~"-/&~1J;::{'JJd2-!j ~~ ~ . 

Thomas O. 'Orvald, M.D. W A # MD 00016180 

Today's date: l'October 2008 Expiration date:· . 1 October 2009 

Risks and benefits of me.dicaJ marijuana: 

Under Washingten state law, the use o.fmedical marijuana is new permissible fer seme patients.with 

terminal er debilitating illnesses. The law regulating this (RCW 69.51A) allews physicians to. advise 

patients about the risks anci benefits ef the medical use o.f marijuana. 

. . 

The medical and scientific evidence supperting the use ef medic,al marijuana remains centreversial in 

the medical cemmunity. Net all h'ealth care previders believe that medical marijuana is safe er 

effective and some providers feel that it is a dangereus drug. . . 

Accerding to. the Washingten state law the benefits ef medical marijuana may include treating nausea 

and vemiting frem.chemo.therapy; AIDS ~asting syndrome; severe muscle spasms frem multiple 

scleresis er other spasticity diserders; glaucema; and seme types ef intractable pain. 

Some ef the risks ef medical marijuana may include po.ssible long-term effects ef the brain in the 

areas of memery, co.o.rdinatio.n and cegnitien; impairment o.f the ability to. drive or operate heavy 

machinery; respiratory damage; pessible lung cancer; and physical er psychelogical dependence. 

Text en this ferm provided by the Washingten State Medical Asseciatien. 

PDU-6655-3000318



P.O. Box41100' Olympia, Washington 98504·1100 

March 26, 2009 


DearMr·1iIII 


Department of Corrections' Health Services physician, your reql.).est has b~en denied. 


. April 1 7,2009. Please send your request t.o the address·below: 



Department of Corrections . 

P.O. Box 41126 . . 

Olympia, WA. 98504-1126 

Your request must provide additional information t)J.at was not included with your original request. 

. Appeals that do not contain new information will be denied.. You will receive a response to your 

appeal request within 30 days of receipt. . . 

Sincerely, 


Community Corrections Divisi"on 

KJ5:md 

cc: Michael.Ison, Community Corrections Supervisor 

Lee Cecil, Community Corrections Officer· 

FieldFile-_ . 

o recycled p'p


From: 

Sent: 

To: 

, Cc: 

Subject: 

Johnson, Deborah A.. (DOC) on behalf of Hammond, G, Steven (DOC) 

Monday, March 23, 2009 3:02 PM ' 


~(DOC) , 

~MRequest 

..... request f,r authorization for use of medical marijuana does not mee! criteria fbr medical necessity. 

1 

PDU-6655-3 000320


,rfcr~ 

: 

t " 

~\ STATEOFWASHINGTON 

• DEPARTMENT OF CORRECTIONS 

Medicinal· Use of Marijuana Verification 

. , 

; 






behavior. Often illicit drug use is a contributing factor in an individual's·criminality. Accordingly it's usual that the court or 




assistance. If you have questicris please feel free to persoiiaHy contact the Medical Director of the Department at (360) 

725-8700. 

1. Is 'this patient under your care 

2. Are you recommending medical marijuana for his pa~ient due to a diagnosis .of Acquired 




Ql'Yes 

DYes 

DYes 

DYes 

DNo 

g/No 

DNo 

DNo 



DYes 

If the answer. to question 3 is "Yes", has the patient failed to respond to conventional 

DYes 


b. If the answer to question 3a is "Yes', please describe what those treatments were (medication, dose, 

duration): . 

G]'No 

DNo 


4. If you answered "No" to items 2 & 3 above,. what is the reason you are recommending medicinal US!;! of 

marijuana 



. 5.' While on community supervision ("parole") the Department of Corrections only authorizes the 


use of mec,iical marijuana, will you be prescribing only the oral synthetic formulation 

6. The patient's accompanying Release of Information auttiorizes you to provide the 



0 Yes 

DYes 

ErNo 

[Q-No 

DOC 14-053 (Rev. 7131108) DOC 380.200 

PDU-6655-3000321


Prescriper's Signature 

3-i-O~ 

Date 

License #: 

:lS,illtV\ Sc..\Art>L\; "j{lv" . o{~ j't: e 


l,.icense type: 

Phone Number 




, Washington State Department of Corrections 

PO Box 41123 


~IAR 1 8 2008 , 

()ept O'~ 


'~ ... \~.:11·0~;i;iUl1~· 

TO'be filled out by DOC' Physician: 

I have reviewed this verificatin form ~ find that' use O/:f, ' dical marijuana by this patient 

,(check one) I 0 IS' [Mfs not " " 

,consistent with DOC POlicy. , 

.... MI Il- 


Date 

' 

Instructions to D~C Physician: 

When form is complete:' 

1. Email your finding above tothe Assistant Secretary for Community Corrections 

2. File this form and the accompanying Release of Information in Liberty as a Community Corr~ctions Health Record. 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infonnation without the specific written consent of the person to whom it pertains, or as otherwise 


' 


PDU-6655-3 ,000322

I 

1 

i i 

I 

I 

I 

j' 



P.O, Box 41100' Olympia, Washington 98504·1100 

March 26, 2009 

Dear:Mr._ 


Department of Corrections' Health Services physician, yoUr req1.J,est has been denied. 

You may appeal this decision by sendmg your written request within 15 business days; on or before 




Department of Corrections , 

P.O. Box 4.1126 \ 

Olympia, WA 9,8504-1126 

Your request must provide additional information that was not included with your origmal request 

Appeals that do not contain new information will be denied. 'You will receive a response to your 


, , 



KD:md 

cc: ' Robert Pearson, CommUnity Corrections Supervisol' 

Russell Alfaro, Community Corrections Officer 

Field File 

Physician' ~ Office: 


1813 130 th Ave. NE#210 

Bellevue, W A 98005, 

'~Working Together for S~F~ Communities" 

i 

~ recycled paper 

PDU-6655-3 000323


From: 

Sent: 

To: 

Cc: 

Subject: 

! 

I 


Friday, March 06, 20099:10 AM 

Daniels, Karen R. . Distefano, Monica J. (DOC) 

MM Hammon:~d~,~;G~;':III"illI"lIlI 

Req ..., 

The following requests for authorization for use of medical marijua~a do no~ meet criteria for medical necessity: 

1 

PDU-6655-3 000324


1813 130 th Ave. NE #210· 

Bellevue, ·WA 98005 

Phone: 425-869-6186 or 800-723-0188 

iRECEfVED 

liAR 0 3. 2009 

Dept of Corrections Health Services 

RECEIVED 

Fax: 425-869-6378 

MAR' 0" 2009 

. www.tht-foundation.orq. www.hemp.orgDAPt,p10;1rreCtIOn~ 

Documentation of Medical Authorization to Possess Marijuana T~~'cf1ltra9Jc;~ts 

Purposes in Washington State 

The text of this form was recommended by the Washington State Medical Association. 

s 

Patient Name: 

Date of Birth:--=.u. 

I, Thomas Orvald, am a physician licensed in the State of Washington. I am treating the 

above named patientfor a terminal iHness or a debilitating condition a's defined in the RCW 

69.51A.OIO. I have advised the above named patient about the potential risks and benefits of 

the the medical use of marijuana. I have assessed the above named patient's medical hi;;tory 

and medical condition. It is my medical opinion that the potential benefits of the medical use of 

marijuana would likely outweigh the health risks :for this patient. . 

Signature of Physicia~: --,:,::--_. ~---I!-==~:;..J' 

~~,,:......:......,..,-.~=-()--,~,.....,....,...u--:---:-~_--,-_c_th 

Thomas Orvald, MD WA #. MD 00016180 . 

__· (;,_(_'" 

Today's Date: i.j@JY)H~D~ I Q . .gOO 1'· Expiration Date:,. YLXVU,1aeJ if:) 020/0 

Risks and benefits of medical marijuana: 

'Under Washington state law, the use of medical marijuanais now permissible for some patients 

with terminal or debilitating illnesses. The laws regulation this (RCW 69.51A.) .allows physician's 




marijuana is 'safeor effective and some providers feel that it is a dangerous drug. 

According to the Washington state law the benefits of medical marijuana may include treating 

nausea and vomiting from chem,otherapy; AIDS wasting syndrome; severe muscle spasms from 

multiple sclerosis or other spasticity disorders; glaucoma; and some types of intractable pain. 

Some of the ris!

01/21/2008" 20:06 2534724155 VEHICLE PICKUP PAGE 02/04 

/"" .... , 

l~ STAT!; Cf"WASHINGTON 

~ CeARTMENT OF CORReCTIONS 


OFFENDER 1.0. OATA: 

To be iiiiea oui: by Prescriber: 


By state staMe the Washington State Department of Corrections is charged with the responsibility to supervise some 


Dgparirnant. Supervision is designsd to help the offender avoid those environments or situations that lead to t'1eir criminal 

behavior. Often illicit drug use is a contributing factor in ari individual's criminality. Accordingly it'susuaf that tne court or 


including marijuana. This offender has claimed ·that they have a condition for which the medicinal use of marijuana has 

been recommended. The below verificafion is to determine the legitimacy of their claim. Thank you in advance for your 

VEHICLE PICKUP 

PAGE 03/04, 

,I 

·;tit i~r4JC~!l/~k~~.ti~4 .(];;Awd iJ1 

Prescriber's N .. m~Pl1nt) 

Prescrij)ar's }Slsrtatura 

License #: ~{//\ 4t Jf;ffi ceo I b [ SO License type: 

Prescriber's Adcress IBB l~.I'\...AVe N2 Phpne Number 

~r.{,U q;(}~. qgoo.~ , 

P!,"escr!ber: please return this form and tl1e patiantlsReleasa of Information to; 

/.-J!):.200 

Date . 

Medical Director . 

HeaJth Service~ Division 

.Washington Sta.te Department of Corrections 

PO Box 41·123 

/I hOI ,pia, Wf\98504-2113 // 

c-/-" e/~ f,//~ ~,' ,~1 ~-- 

~IZ AJr.-fjt7w-~ ~(/d //~__ ~ .i/t, ~ ~a 

"'-7 7/·, (/ /, 

To be fllle~ out by DOC Physician: . 

I have.reviewed this verification form Mef find that use of medical marijuana by this patient 

(check one) lOis l1ais not " ' 

consistent with DOC Policy., . #.r; A I " . " 

aT as. . 1- . , r:g;lftJ~ 

Physician's Name (Pont) 


Date 

instructions to DOC Physician: 

When. form is complete: 

i. Email your finding above to the Assistant secretary for Community Corrections 

2. File thiS form and the accompanying Relea~e of Information in Libe~ as a Communitl Corrections Health. Record. 

State law' (RCW70.0Z; RCW 70.24.105j RCW 71.05.390) and/orf~c!e~l ;eg!Jtatic;ms (42 CFR Part 2; 4S CFR Part 1a4l I'rQhlbit 

disclosure oftfoi,. information withoutlba specific 'Nrl2:'~n consent of tne pel"$on to whom it perts.ins, or as otherwise 


DOC 14-053 (Rev. 71W08) . DOC 380.200 

PDU-6655-3 000327

#fOr~ . 

.,;f ~ . 

{rri'~l STATEOFWASHINGTON . 

L!I.N DEFARTMENT OF CORRECTIONS 



OFFENCE" 1.0. DATA: 

herePY authcrize the use or disclosun~ of my health information 

'as described below. The following individual or organization is authorized to make the disclosure: 

NAME:. T t+ c F i'1 e.i,"(!Cl..! c.. {z'~1. /r . 

. ADDRESS: I ~i7 13 0 ,H Ptve. A.J E :fi;.- I Cl 

. (J e. 77 e veu::- :~,; A ~ f(fk"7.r 

. .' 

The type and date(s) cf information to be used or disclosed is as foilcws: 

,4;1",....., 

Purp,ose for disclosure: JIle. J/cc< 11& >'\. 

~~~~--~~--------------------------------------~----- 

I understand that the information'in,my health record may include infonTIation relating to sexually transmitted 

infections, ~cquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HI\/), It may also 

include infonTIation "about behavioral or mental health services and. treatment for alcohol and drug abuse. 

This infonTIation may be d.isclosed to and used by the following' individual or organization: 

NAME: __________________ ~----~--------------- 

ADDRESS: 

I..IMGv\U;.f.&,I1. 9~ DeH of C~rrecf.eli. J 

Po £1.0;(" l//I 1. ') .' 

J J i " . 

I understand that I have.a right to revoke this authorization at any time. I understand that if I revoke this 

authorization I must'do'so in writing and present my written revocation to the Health InfonTIatio[1 Management 

Department. I understand that the revocation will not apply to infonTIation that has alredy beeri released in 


or condition: 

(if left blank, authorization will expire six (6) months .froms/gning), 

I understand that authorizing the disclosure of this health infonTIation is voluntary. I can refuse to sign this 

authorization, I n.eed not sign this form in order to assure treatment.. I understand that I may inspect or copy the 

information to be used or disclosed, as prolJided in CFR 164,524 and RCW 70"02, I understand that any disclosure 

. of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal or 

. stats 'confidentialitv rules, If I have questions about disclosure of my health information, I ma~ contact the 

RHIT/designee of the 

Signature of Patient 

ifformi~) .. 

~ 

Date of 8irth 

Date 


~ 

DOC Number 

Signature of Witness 

Date 

. Slate l([Iv (RCW 70. 01: RCW 70.24.105: RCW 71 ..05.390) and/or federal reg

STATE OF WASHINGTON . . 


P.O. Sox 41100' Olympia, Washington 98504-1100 

March 26,.2009 

Dear Mr._ 

I received your request from your physician on Pebrll"'!y 16, 2009, to appeal the denial of 

your initial Medicinal Use of Marijuana Verification. 

In the interest of public safety and protection Of the community at large, I find your 

. request for Medicinal Use of Marijuana: while under the supervision of the Department 


. . 

. I would encourage youto continue to program in a positive manner, following the 


Karen Daniels, Assistant SecretarY 

Community Corrections Divisiop. . 

KD:md 

cc: Misi Nimese Liulfullaga., Community Corrections Supervisor 

. Erin O'Donnell, Community Corrections Officer 

"'Pield'Pile=DOC_ 

. 

... ..... ...... .. ..... 

.. 



CBRMedical 


Spokane, W A 99202 

, 


0. rccj'c!cd pupcr 

PDU-6655-3 000329

3115 E. Mission Ave . 


i 

; 

o Please Reply 

0 iP'ieese RecycOe 

;;~"ts.!£~/ J I / ~ ~ 

~" j) ~ ~ 

~ft; -, ~ f)U.'- '1 fi


.DEPARI'MENT OF CORRECTIONS 



Dear Mr._ 

Your Medicinal Use of Marijuana request 'Vas received on Januruy 14, 2009. Upon review by the 

· Department of Con-ec~ons' He!llth Services physician, your reqties~ has been denied. 

You may appeal this decision by sending your written ~equest within 15 business days of this letter, 

· which is on or before February 16, 2009. Please send your request to the address below: . 

Karen Daniels, Assistant SecretarY 

Community Correction.s Division 

Department of Corre.ctions . 

P.O. Box 41126 

· OLympia, WA 98504-1126 

Your r.equest ~ust provide additional information that was not· included with your original request. 

Appeals that do not contain new information will be denied .. You will receive a response to your 

app'eaI reguest within 30 days of receipt. 

smp~~ 

~al1ieIS, Assistrult Secretary 

C0rItmunity Con~ectioris Division . 

K9:md 

cc: Misi Nimese Liulamaga, Community Corrections Supervisor 

Erin O'Donnell, Community Corrections Officer 

Field File 

Physic.jan's Office: 


CBRMedical 



" WorJdng Together for S(J.FE Communities" 

PDU-6655-3000331

·STATE OF WASHINGTOI< 

DEP.~RTI'iIENT OF CORRECTIONS 

AUTHORlZA TION FOR DISCLOSURE 


The following individual or organization is. authorized to make the disclosure: 

NAME: _-:C::;,1 ~J3~R~/::..::l~1~e.!'L.:/u. ~:-L-(':-.




OFFENCER I,D CATA: 

I 

I 

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By state statute the Washington state Department of Corrections is charged with the responsibility to supervise some 

offenders after they have been convicted qf a felony., The above named patient is currently under supervision by the 


behavior. Often illicit drug use is a: contributing' factor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs; 

including marijuana., This offender has claimed that they have a condition for which the medicinal use of marijuar.Ia has 



~~' / 

' 

1. 15 this patient under your care /2Nes 0 No 



'e. If the answer to question 2 i~ "Yes:', does he/she have anoraxia 

b. If the, answer to question 2a is "Yes", does he/she have weight loss 

3. 'Are you recommending medical marijuana for this patient due to nc~usee and vomiting 


4. 



r [ V 

DYes 

DYes 

DYes 

DYes 

DYes 

b. Ifthe answer to question 3a is ·Yes", please describe whatthose treatments were (medication, dose, 

duration):' 

c. What is the planned schedUle of chemotherapy I 

a. 

, ,;VI~ 

If you answered "No" to items 2 & 3 above; what is the reason you are recommendingomedicinal use of 

marijuana' 'n I\.. r, j ~ ~ 

.' cJ~, h~'I""~' ~ "'---' ' 

~ 

~' 

~ 

Z No' 

Please prov.ide evidence published in a peer-reviewed scientific publication to support t.he medicinal use of' 

marijuana for this purpose " _ () • 

----~----.-'-------~.,J-e...~ ~~~\~ 

i 

i· 

1 

I 

5. While on community supervision ("para Ie") the Department af Corrections only authorizes the 

use of the oral synthetic formulation of mariJuana. If the Department authorizes this patient's 

use of medical marijuana, wlilyou be prescribIng only the oral synthetic formulation 

6. ,The patient's accompanying Release of Information authori~e~ you to provide the . 

Department with current and future information related to this Issue. Do YOll agree to notify 


DYes 

DYes 

DOC 14-053 (ReV: 7/31/08) 


PDU-6655-3 000333

. p(J !/j~1 ·.;IS-.·j / 

Prescriders Name (Print) 

.~ ! 

!\ ,"- 

License #: f/!} boo Q / \("3// License type: . A.4.D 

~~~~-------------------- 

Prescriber's Address '"3/(5" E-iU,'5S,'G)~ fivp . Phone Number 

. 5fv ..qn.o r vJC'/. Cfq z@ z.. 

Prescriber: please return this form and tile patient's Release of Information to: . 


Hea!th Services Division 

Washington State Departmentof Corrections 

PO Box 41123· 

Olympia, WA 98504-2113 

, \ 

SOc;· 570";2-·8'"""66 

Seq ~ .J-

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I. 



PATIENT NAME: ___ _ IATE OF BIRTH: ~ 

f, Dr. Mohammad H. Said , am a physician licensed in the State of Washington 

and lam treating the above patient for a terminal illness or a debilitating condition as defined by 

RCW 69.5'IA-OiD. . . 

! have advised .tile above named patient about the pptential risks and benefits of the medical. use . 

of marijuana. I have assessed The above named patient's medical history a'nd medical. condition. 

ft is my medical opinion that the potential benefits of the medical use of marijuana may outweigh 

the health risks for tilis patient. 

Physician Name: __:;;,D",-r 

•.:.:M.:.:o:..;,il;::a:;,:m.::.m:.,:;a:;,,:d:;..:...:H:... S:::;a::..;i.::;,d ___/se Number: 

MD00018311 

Physician Signature: ~'lf ~ c:u...

~r.~''''' 

OFFeNDER 1.0. DATA: 

( ~ STATEOFWASHINGTOIII 



OF HEALTH INFORMATJON 

hereby authorize the use or disclosure of my heal~h information 


NAME: en \iL . \J\& _A~ c.... ..... \ . 

ADDRESS: __ ~~~~I~I_~~,~t::~·~.~.~c{~A~',~'·~S~~_d~;~·£>~'~~~~~~~~'l-__ __ 

~.o.e C4 I\, I) I..A..9 0 '7" q Z. (') "2 . 

~ l 

The type and date(s} of information to be used or diSC~O ed IS as fonows: . 

.,\ r. r" r\ --f- r 1\ ...J..... (,/ 

J Q., I~ C. "l !{(~)"\. 0 q- i~!...{ fi C ,7 Cdl i)h 6 ~ 

. c 5- ..i 

(p 7. I.IT 

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Purpose for discJosure: ___\J'~e=-!..{'-.!...·; 4-p._·-,II-...:C=·;;;:"'~:.:'1_-1.'::';~·O:::::"':V'I.~-t."..":;,.~C=:,,,......,.

i 

I. 

I 

OFFENDER lO. DATA: 



Medicina! Use of Marijuana Verification 



By state 'statute the Washington State Department of Corrections is charged -ATith the responsibility to supervise some 

offenders after they have been convicted of a felony. The above named patient Is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations thaflead to their criminal 

. behavior. Often illicit drug use is a contribUting factor in an individual's criminality. Accordingly ifs usual that the court or 

the Department·of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, 



assistance. If you have questions'please feel free to personally contact the Medical Director of the Department.at (360) 

725-8700.' '. . / 

1. Is this patient under your care c:a4es 0 No /' 

2. Are you recommending medical marijuana for his patient due to a diag'nosis of Acquired 0 Yes (2l~ 


3. 

4. 

a. If the answer to question 2 is "Yes', does he/she have anorexia g Yw El No 

b. If the answer to question 2a is "Yes·, does he/she have weight loss D"'>"IM'e"'s..--f-cr+No 

Are yot! 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 


DYes 

~. 

Q.¥es--iJ No 

b. Ifthe answer to question 3a is "Yes', please describe what those treatments were (medication, dose, 

duration): {l'o. I '()1- 1\ -" \.. ' 

. V /.-\ P f \ N"-

J\' ~ ", 

< .-, 0 '1...... . 

-n=:::,:;;:/:-:::;-:-:::/..-' 

........ ;-. 

~.,-;-' 

-,,!./~.:'~-' I_~.;::::;.",,-, _____ 

/" I' .-"~. 

--L/::k_ 

Prescriber's Name (Print) . Prescriber's Signat1 / +- 

,~... '\' l '1.., • 

~J

3 i 15 E. Mission Ave 


o Urgent o For Review . D Please Comment 0 Please lReply 0 Please ~·scycne 

-Comments: 

- . {. 

~ L/VL,.cjL\j!.-/ ) ) 

. U . "-'j 

;YlJ~~ ;hr 

---:---.----:---~-...::...-~5" e--c-r- '5 -;; 0 .,) 'i' " f 

CBR Medical, Inc. - 3115 E.-Mission Ave, Spokane, Wa. 99202 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710. 


! 

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exempt from disclosure under applicable law. You are hereby notiiied that any dissemination, 


deSignated agent is strictly prohibited. 

Alllnformaiioll is Protected Under U.S. Federal Law 

PDU-6655-3000339

i 

I 




_ __ ,DATE OF BIRTH: -..!!!!!!!!!!!!I!!!I!!!!.::..::..:....:=-- 

I. Antoine Johnson . am a physician licensed in the State of Washington 

and I am'treating the above, patient for a terminal illness or a debilitating condition as defined by' 

RCW 69.51A.010. 

' 


of marijuana, I have assessed tlleabi:Jve named patient's medicql histolY and medical condition. 

It is my medical opinion that the potential~efits of the medical Lise of marijuana may outweigh 

the [lealth risks for this patient. / / .' 

Physician Name: Dr, Antoine J,chns/n WA License Number: MD00039048 

,I / 


.1,"+--- 

1 Dale: 01/09/2009 

This recommendation expires on: 72/05/2009' . 

Risks and benefits of medical marijulna ' , 

Under Washington law, the use 0, medical marijuana IS now permiSSible for soma patients 

with terminal or debilitating illnesses, The law regulating this (RCW 69.51A) allows physicians 

to advise patients about the ris/

Documentation of Medical Authorization to Possfo'ss Marijuana 

" for Medica! PLlrposes in Washington State 


DATE OF BIRTH: ---,__,-i.:..97:-S,-- 

i 

,I 

I 

I, Dr. Mohammad H. Said , am a physician licensed in the State of Washington 

and I am tre


From: 

Sent: 

To: 

. Subject: 


Monday, February 23,200910:40 AM 

Liulamaga, Misi Nimese I. (DOC); O'Donnell, Erin M. (DOC) 

We received an appeal to Mr ••• lmedicinal marjiuana denial from his physician. 

Please dO not proceed with ·any violations related to the medicinal marijuana until the decision has been made on the 

appeal in the next 30 days. 

I will let you know the outcome.· 

Thank you! 




Community CorreCtions Division 


Tumwater, WA 98501 MS: 41126· 

(360) 725-8796 


1 

PDU-6655-3 000342


DEPARTMEN'T OF CORRECTIONS 

P,O, Box 41100' Olympia, Washington 98504,1100 



.·DearMr,_ 

Your Medicinal Use ofMarijuaniHequest was received on January 14, 2009, Upon review by the 

Department of Corrections 'Health S~rvices physician, your re_ques~ has been denied. 

You may appeal this decision by sending your Written request withln 15 business days of this letter, 


Karen-Daniels, Assistant Secretary 



P.O. BoxA1l26 

Olympia, WA 98504-1126 


Appeals that do not contain new information will be denied. You will receive a response to your - 

appeal request within 30 days of receipt, _ - - 

KD:md 

cc: Misi Nimese Liulamag~ Community Corrections SuperYisor 

Erin O'Donnell, Community Corrections Officer 

Field File . . 



CBR Medical - 



o recycled pap" 

" Working Together for SAFE Commu.nities" 

PDU-6655-3 000343

;lan.14. 2009 9:52PM CBR Medical Inc. 

[';pokane, WA !J020 

~nOQiCD~ 1ltf.~fefC\JCllj 

~x: .. Pi.i):-f:f.io -C12J)2.... 

~rOin: m[lI~O;':~ ...:I~ ~ /\ 'btO 

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Tti··CitiAs Phl.lne 609·t\1f-)-22fJ7 \-8X GOg· :140-2710 VaT\CCillVer PhurtF. :ltiO-B35 ·(:)4611' Fnx 206-J1:1B (1659 

GONrlDf-NTIAUI Y NOTICT:: TlllR cDll"lmImlcation iF. intcndl~d for lhe f.ofe Lise of the indiVidu,-ll

Jan. 14. 2009 9 : 53 PM CBR Medical Inc. No.3105 P. 2 

,/""".'''', OrrENClF.R I.L1. L'lA1 A: 

.,~.. DS!'IARTMENT OF CORRECTIONS 



"r,,,,"n,.,.,,,",," iii liIllthnri71"rt tn mAkf' fhp ciii'it.lnAllfA' 

NAME: Cy\~Q"~V\!f) c\.:'~ C'-#' .." \ .. " ____ 

:--, ( ", 'G~.. foo"l.

Jan, 14, 2009 9:53PM CBR Medical Inc, No,3105 .p, 3 

OFFF.NDClUI.l. OA'rA: 


DEPARilVlENT OF CORRECTIONS 


. . 

To be out 

r patien~j.S .. Name. 

TD be filled out by Prescriber: 


By state statute the Washington State Department of Corrections is charged with the responsibfiity to supervise some 

offenders after they have been conVicted of a felony. The above named patient is currently under supervision by the 

Departrnent Supervision is designed to help the offender avoid those environments or situations that lead to their criminal 

behavior'. Often illicit drug use 15 a contributing f f1F'nFlrtmp.nt Of ~0r.rections onlr authorizes the' 

Use ofthe oral syntnel:rc Tormutatlon ojmalIJ'l;tdl~a, 1('/""C'\!J~p6I'(,\ w,,' -:... ~ ,-,.- - :-.. , ,..., 

use of medical ~arijuana, will you be prescribing only tile oral synthetic f-ormulation 

/,' 

6. 

The patient's accompanying Release of Information autllorize~ yau to provide.the . 

Department with current and future information related to this Issue. 00 you agree to notIfy 

the Department's Medica! Director of any changes in your answers above 

DYes 

~ (Rev. 1/31/08) 

DOC3B0200 

PDU-6655-3 000346

, Jan. 14. 2009 9:54PM CBRMedical Inc. 

No.3105 ·P. 4 

Prescribe.: please return this form and the patient's Release of Information to: 

'ro be filled out by DOC Physician: 

Medical DireGtar 

Health SSNices Division 


PO Box 41123 

Olympia, WA 98504-2113 

a.a. T&M 

Physician's "Name (Prirl-t}--' ~"--..... PhYSloiciii's Signatt1re .--_.. --.. . 

,I have reviewed this verification form aoel' find that use of medical marijuana by this patient 

(check one) lOis IZa1s not ~ , 

consistent Wit/1 DOC Policy. " 

~ 

Instructio!lS to DOC Physician: 

. ___ .. ____ . _ " ____ O,._M_._ .. ' __ 


1. Email your finding above to the Assistant SecretalY for Community Corrections 

2. File this form ond the accompanying Release of Information in Liberty as a Community Corrections Health Record. 

State law CRew 70.02; RCW 10.;t.l..10Sj ROW 71.05.390) aml/l;w fedoral ragulation$ (42 CFR Part 2; 45 ci-R Part 164) prohibll 

dl$closure ofthislnformmiorl wltho.ut tl1especifh: written consent of ~hl). person to Whom it pertains/'or ;1$ oiherwise 

p.ermitted by law. 

DOC 1~"053 (R$v .. 7/31/0(J) 

DOC 380,200 

PDU-6655-3000347

Ja n,. 14,2009 9:54PM CBR Med i ca r Inc, No, 3105 p, 5 

Docurnentatk)n of iVledical Autrlorizai:ion to Possess Marijuana 

for lVI.edical PI.lrposes in Wasl'tington State 

PATIENT NAME: ONE OF BIRTH: . ___ ~ 

I, 'Antoine Johnson __ . ______ .' am a physician Iicer1sed in the State of Washington 

and I arn treating tlie above patient for a terminal illness or a debilitating condition as defined by 

ReIN 69,51A010, . 

I have advisee! the above namee! patient about the potential risks and benefits of tile medical use 

of marijuana. I have assessed the above naJ)"Ied patient's medical history and medical condition. 

It is my medical opin ion that the potential,Jtel'lefits of the nledical use of marijuana may outweigh 

the health risks for tl1is patient. . / / 

I I . 

Physician Name: _. __ ...!2.r: Antoine yphnspil ____ .... WA Licel1se Number: _____ . ___ ~000390~. 

// ,----L ____ ,~ __ 

Physician Signature: ~_--,._., _..,-.I--__ ~_.~. ~_ 

-' 

Date: __ O;,..;.1 ..... !O.;.;9/.;;;.20.:..:0~9___ 

Ri,c;{{$ and benefits of medical mariju na 

Under Washington law, the USE1 0 medical marijuana is now pelmissible for some patients 

witli terminal or debilitatil19 ,illnesses. The law regulating this (RCW M.o 'I A) allows physicians 


. The medical and scientific evidence 5UPPol11ng the use of medical marijuana remains 

controversial in the medical. community, Not all health care providers belieVe tbat medica! 

marijuana is safe or effective' and som9 providers feel that it is a dallgerous drug_ 

According to the Washington State law the benefits of medical rnmijuana may include 

. treating nausea and vomiting from chemotherapy, AIDS wasting syndrome,severe mU!;lc!e 

spasms from multiple sclerosis or other spa"iicity disorders, gla.ucoma, and ome types of 

intractable pain: . 

Some of the ris·ks of medical marijl.lan~ lTlay include popsible long-term effects· of U1e brain in 

the ·areas of memory, coordination and cognition: impairment of the. ability to drive or operate 

tleavy machinery; respiratory damage; possible lung cancer, and physical or psychological 

dependence. 

Recornmend"diorl . . . 

As this patient's "60 Day Supply", as stipulated by RCW 69,51A.040 (3)(b) and' 

WAC 24~-75 .. 01 0, this QLlalifying Patienf can reasonably expect to have in tl1eir Posess ion and 

Need a total of no more than ~4 Ounces of {(Usea~adj~J.aD.a~aDd.o.oJ.lio.r.eJt\.an..15_elants ___ ----- 

. CBR Medicat Inc. 



, 

i 

I 

SpOkane: 509-242-8624 Fax:509-340-2710 

Seattle: 206-774-6493 Fax: 206-418·6659 


CALL 509-570·2886 OR 509-570-6943 . 

PDU-6655-3 000348

.Jan. 14. 2009 9:55PM CBR Medical Inc. No. 3105 P. 6 



P.A..TIENT N!\ME:; ___ ~, DATE OF EI!RTI!: 


and I am treating the above patient fur a terminal ilfnsss or a debilitating condition as defined by 

RCW $9 . .51A.O·lO. 

I have advised the apove named patient about the potentii;\I risks and benefits of the rnedicnl use 

of marijuana. I have assessed the above named patient's medical history and medical condition . 

. It is my medica! opinion that the potential penefits of the medical use of marijuana may outweigh 

the health risks for this patient, . 

Physician Name: _-..::D~r!..-'. M,,-,o::;:.:h;.:,::. a~rn.:.:.n:.:.:la::;:dc..:.H.:.:. ...::Sc::S1,."id__ WA License Number: 

Mf.)00018311 

-. :........... .~------ 

/t,< rL to C~(J 

Physician Signature:_ Date: 12105{2008 

This recommendation ,expires on: ~/2009 

I' 

! .~. 

1 

" 

.. 

.; 

Rislrs i.md benefits of mer;iical marijuana 

Under Washington law, the usa of medical marIjuana is now permissible for some patients 

. with terminal or cjebilitatlng iIIneases. The law regulating this (RCW 69.51 A) allows physicians 

to p!dvise patients about the risks and benefits of the medical use of marijuana. 

The medical and scientific evidence supportIng the use of medical marijuana remains 


marijuana is safe or effective and soma providers feel that it Is a: clangerou5 drug. 

. Ar,e;ording to the Washington State law the. benefits of medical marijuana may indudri . 

treating nausGa and vomiting from chemotherapy, AIDS wasting sync!rome, severe muscle 

spasms from multiple :sclerosis or oifier spasticlty disorders, glaucoma, and' some types of 

intractaple pain. 

Some of the riSKS of medical marijuana may include possible long-term effects of the brain in 

tile areaS of memory, coorc:lination and cognition; impairment of the ability to drive or operata 

Iu P J.l m *lli"'11I .lfIoinnlnnr rlnmnl1o· nnrritlln lImn rllnrii linn nhu~irlll nr mlfrihnlnnlni'll 

Recommendatfon 

As this patient's "60 Day SupplY', as stipulatea by RCW 69.51 A. 040 (3)(b) and . 

WAC 246-75-0'1 a,this QualifYing Patient can reasonably expect to have in their Posession and 

Need a total of no more. than 24 Ounces of ·Useable Marijuana" and no more thCln 15 Plants. 

CaR Medical, Inc. 

Administrative Offi~ 

3115 E. Mission Avo, Spokane, WA99O/. 

Spokane: 509-24/.-B624 Fax:509-340·2710 

Seattle: 206-774-6493 Fax: 20e-418~6659 


II II ........ u In 

PDU-6655-3 000349



P.O. Box 41100· Olympia. Washington 98504·1100 

March 26, 2009 

Ocean Park, WA 9864Q 

Dear Mr._ 

I received your request from your physicia..n on February 16, 2009, to appeal the denial of 

your initial Medicinal Use of Marijuana Verification. '. 

In the interest ofpubli~ safety and protection of the community at large, I 'find your 

request for Medicinal Use of Marijuana, while under the supervision of the Department 






KD:md 

cc: David Phillips, Community Corrections Superv~sor 

Linda Tolliver, C~ Corrections O.fficer 

Field File - DOC__ . 



------------~-------·C~~B~R'M~. ~eruca1r--=~------------------~-------------------------- 


Spokan~ Wi\ 99202 

a recycled paper 


PDU-6655-3 000350

STATE OFWASHINGTOt-J 



.March 26, 2009 

Spokane, WA 99207 . 

Dear Mr._ 

I received your request from your physician on February 16, 2009, to appeal the denial of 

yoUr initial Medicin~ Use of Marijuana Verification. 

In the interest of public safety and protection of the community at large, I find yoUr 

request for Medicina1- Use of Marijuana, while under the supervision oft1e Department 

of Corrections, is denied. . 


direction of your assignedCCO and your conditions of supervision. 

S.inc:J .",. .:''A. 

~~ 



KD:md 

cc: Jack Brucick, Community Corrections Supervisor 


Field File - DOC_ .. 


Attn: MelissaLeggee 

----------~--------tlf.R-w.realcarl--------------------~~------------------------------ 



" Working TOfiJether for SAFE Communities" 

PDU-6655-3000351



To: 

Fran,: i2&ls"Y.4 € CQ/!:f.~/C;(..,/ .. U;t 1 1 

Date: c2 -- / &: .... :2. ,t)O 9 

I' 

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, ' 

o Urgent '0 !For Review o Please Comment 0 !Please lReply , 0 Please Recycle 

CBR Medical, Inc. - 3115 E. Mission Ave, Spokan~, Wa 99202 


Tri 7 Cities Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 

COf\IFIDENTIALITY NOTICE: This commuilication is intended for the sale use of the individual and 

entity to whom it is addressed, and may contain infonnaiion that is privileged, or confidential and 

exempt ITom disclosure under applicable law. You are hereby notified that any, disseminatiqn, 



' 

AI! Information is Protected Under U.S. Federa! Law 

, 

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PDU':'6655-3 000352

STATE OF WASHIi'JGTON 


P.O. Box 41100' Olympia, Washington 98504·1100 


Dearlvfr._ 

Your Medicinal Use of Marijuana request V'las received on January 8, 2009. Upon re-view by the 

Department of Corrections' Health Services physician, your request has been denied .. 


which is on or before ,February 16, .2009. Please send your request to the address below; 


Community COlTections Division 

Department of Con-ections ' 

P.O. Box 41126 

Olym.pia, WA 98504-1126 

". Your request must proVide additional information that was not included' with your original request. 



Sinc11~J', 

S~ 

rl,D..n'b, """,,trurt 

Community Con-ections Division 

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KD:md 

cc:. Jack Brucick, Community Con-ections Supervisor 

Douglas.Holland,..Community-Con::ections.Officer------___ .___________-+-- 

Field File . . 

PhysiCian'S Office: 


CBRMedical 



." Working Together for SAFE Communities" 

PDU-6655-3 000353


Spokcme, WA 99202 

o Urgent o For Re'lliew o Please Comment 0 !Please !P.eply 0 fllease Recycle 

-Comments: 

. ) 1- 

va t·""fJ 

, 

I 

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1 

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CBR Medical, Inc. - 3'\ 15 E Mission Ave, Spokane, Wa 99202 

Seattla Phone 206-774-6493 Fax 206-418-6659 Spol

'OFFENCiER 1.0. DATA: 




OF TH INFORMATION 


as described below. The following· individual Of organization i~ authorized to make the disclosure: 

NAME: (' j512 .--Alec/; c. ..-.J! ..1.1 C 

ADDRESS: .3 J I S~ e ., ,.,,41/' S ,',0 /) /d.t! ... 

~l.Jo t::d 17 t:7 , 

. 

tJtJ ~ 99 W 2. 

( 

A-U+k.Q r, "7 ti. 1,'",'"1 /:;; t/ x. /Zit· c/ " Cfi-,.J 


V t.. (',',( c ~'" 1':c)v-,' 0 r: 

Purpose for disclosure:.-'.~,-,-,.,.~.w:;r-t:.....k.!>"":!;~_.:.laG:;"':';;--=-""':'_..i-l..I......::..!::-=--c.!~-'-~~""!-..L! ___ _ 

.1 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 info,rmatlon about behavioral or mental health services and' treatment for alcohol and drug abuse. 

This information may be disclosed to and used by the following individual or ~rga9\zation: 

. . NAME: It)~g£/'::ft.... 3/tf< Dr! &>' ~ C-hl'f'e c. (, ii .,(..s 

ADDRESS: .' ' 

.-to., 

, 

i , 

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authorization I must do so in writing and present my Written revocation to the Health Information .Management . 

Department I understand that the revocation will not apply to information that has already been released in 

response to this authOrizatij' Unless otherwise revoked, this authorization will expire on the fol/owing date, event 

or condition: #.3 n I 0 9 (if left blank, authorization will expire six (6) months from signin~). 

I understand that authorizing the disclosure of this health information is voluntary. I can .refuse to sign thIs 

authorization. I need not sign this form in order to assure treatment I understand that I. may inspect or copy the 

information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure 

of information carries with it the poteniial for an unauthorized redisclosure and may not be protected by federal or 

. state confidentiality rules. If I have questions about disclosure of my health information, I may contact the 

RHIT/designee of the 

:6~::::::':8:;i:::-(:;.l-,e-·-----. -----~-:-- 

Date 

(Patient 10 complete) 

~ I 


Stat.la .. (RCW 70.02; RCW70.24.105; RCW 71.05.390) alld/or/ederal ""lPliations (42 CFRPart 2; 45 CFR ParI 1(4) pralliblta.,,;losllI'Z 

. . orlllls lnflmuatio/l wlthout tile specific lVl°irren consent of the person 10 wltom It pertains. or as othenv;se pe,.mi~fed by law. 

DOC l:l-03!i (05!19120081 POL OOC3BD200. DOC600.020 DOC640:120 DOC 670,020 

LEGAL 

I 

• 

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i , 

PDU-6655-3 000355

OFFENDGR I,D, DATA: 




Dear PresCriber, 

By state statute the Washington State Departmerit of Corrections is charged with the responsibility to supervise some 

'offenders after they have been convicted of a felony. The above named patient is, currently under supervision by the 

Department Supervision is designed to help the offender avoid those environm'ents or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in ari individual's criminaHtY. Accordingly it's u:;;ual'that the court or 


including marijuana. This offender 11as claimed that they have a condition for whIch the medicinal 'use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their cfaim. Thank you in advance for your 

assistance. If you have r:ju8stions please feel fr


e 

License #: 

License type: 

Prescriber's Address e.G rL "... rr-~," r .,) ~\ Phone Number 

, , ( , , 


'Medical Director' 

To be fiIlec;l out by DOC Physician: 



PO Box41123 

Olympia, WA 98504-2113 


(check one) lOis 0 is n'ot 

' 


! 

, . 

I 


{nst~uctions to DOC Physician: 


Date 



2. File'this form and the accompanying Release of information in Uberty as a Community Corrections Health Record. 

State law (RCW 70.02; RCW 79.24,105; RCW 71.05.390) and/or federal regulations {42 CFR Part 2: 4S CFR Part 164) prohibit 

disclosure of this infonnation without the specific written consent of the pi'rson to whom It pertains, or as otherwise 

permitted by law, 

DOC 14-053 (Rev.7/31/08) DOC 380.200 

PDU-6655-3 000357

.IL , 




D~:rE OF BIRTH: -' •• ~96~9~ 

dei>tlitating condffion as defined by 

and benefits of the ~I use 

. leal histofy and medical condition. 

leal use of manluana may outweigh 

Physician Name:_-,,"~~=,,-==:,:;,:,,:,_.,..,.,-- 

MDOOO39Q48 

Physician Sigl1!i!ture:_-+ ____ + __ + __ 

Date: __..;;,.0510-...;.,;312=.;0..;;,.08.;;.....___ 

This racommend!)tion e 

, . 

Risks and benefits of medical merij na 

Under Washington law, the u Of medical rijuana is ncN( permissible fer some patients 

with tanninal or debilitating ill s. The·1 reglllating this (RCW 89.51A) allows physldans 

to advise patJents abOut !t1e Ii and oHhe medlcsl use of marijuana. 

The medical and scierrtffic idence su .'119 lhe use d medical manjuana remains 

controversial in !he medical unity, t alf health care providers believe fuel medical 

manjuana is safe or effective . nd som ·rovide.rs fe.e! that it is a dangerous drug. 

According to the Washin SUI w the benefits of .medlcal marijuana may include 

treating nausea and vomitin from emotherapy. AIDS wasting syndrome, severe muscle 

spasms from muHipie scIe . or spasticity disorder$, glaucoma, and some types of 

iiitractable paio. 

Some of the risks of { rnanjuana may inc!u


From: 

Sent: 

To: 

. Subject: 


Monday, February 23, 2009 10:36 AM 

_); Brucick, Jack M. (DOC) 

. We received an appeal to Mr._medicinal marjiuana denial from his physiCian. 

Please do not proceed with any violations related to the medicinal marijuana until the decision has been made on the 


I will let you know the outcome. 

Thank you! 






Tumwater, WA 98501 Ms: 41126 

(360) 725-8796 . 

. mjdistefano@doc1.wa:gov 

1 

PDU-6655-3 000359

J 



P.o. Box 41100' Olympia. Washington 98504-1100 

Januat'')' 26, 2009 

DearIvfr._ 

Your Medicinal Use of Marijuana request was received on January 8,2009 .. Upon review by the 


You may appeal this decision 'by sending. your written request within 15 business days of this ~etter, 

which is'on or before February 16, 2009. please send your request to the address below: 




P.O. Box 41126 

Olympia, WA 98504-~126 

Your request must provide additional information that was not included with your original ~equest. 

. Appeals that do not contain new information will be denied You will receive a response to your 

. appeal request within.30 days of receipt. . 

J:ftr"l~ 0 

~(~U., 



KD:md 

cc: JacIcBruciCk-;-'Commumty Corrections Supernsor 


Field File 



CBRMedical 

3115 E .. Mission Ave. 


o recyclc:clpapl.'t' 

" Working Together for SAFE Comf!1unitfes" 

PDU-6655-3 000360




March 26, 2009 

WA 98366 

Dear Mr._ 

I received your request from CBR Medical, Inc., to appeal the denial of your initial 

Medicinal Use of Marijuana Verification. 

You have been approved to use marijuana medicinally, in accordance with the law, while 

under the supervision of the Department of Corrections. , 

' 

Your Community Corrections Officer, Scott Wright, will be asked to impose a DOC 

condition that you not oper~te a motor vehicle while under the influence. 

I would encourage you'to continue to program in a positive manner, following the 




KD:md 


Michael" Anderson, Community Corrections Officer 

FieldFile-DOC_.. : . 


-----------,Aftn;--M€lissa..Leggee'-'-------------'------------ 

CBRMedical 


Spokane, W A 99202 

" Working, Together for SAFE Communities'~ 

-0 rccych:d i';tllt:r 

. PDU-6655-3 000361


'Spokane, WA 99202 

To: 

. /: .... 

)2l'11rgent o Please Comment o Please Rep!y 0 Please Recycle 

I 

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"' I. 

I' 

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Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-242-6624 Fa"( 509-340-2710 


CONFIDENTIALITY NOTICE: This communication 'is intended for the sale use of tlle individual and 

entity to whom it is addressed, and l'nay contain information tilat is privileged, or confidential and 

exempt from disclosure under applicable Jaw. You al'e hereby notified that any dissemination, 

distribution, or duplication 'of tllis communication by someone other tilar. the intended addl'Gssee or its 


All Information is Protected Under U.S, Federal Law 

PDU-6655-3000362

4./'~Gr~:;\ 

OFrENOG.RI.O.OAT.lI,: 

{ f STATE OF WASHINSTON 

DEARTi\IlENT OF CORRECTIONS 

AUTHORIZA TION fOR DISCLOSURE 

OF HEALTH INFORMATiON 

hereby authorize the use or disclosme of my health information 

or organization is authorized to make the disClosure: 

Ni\ME: _-,C=I""B'7'-'-R--,-,--"e--,-,1#~:ct,-"" 

eJ.(~--'."C_, ,~&~~/-";",,,,~-(::.c-)n ..... ,. _';,.('~___ 

ADDRES& __ ~,~:1~!~j~~~~~-__ ~C~-~,~)~'V1~f~':~~~S~'~"d~/~~~, __-L'~~'~V~~~____ 

. N ./lJ ,UYer 7' q.. Z/J :2 

. if .,' ' 

Purpose for dlsclosure: _______ ...,-_______________________ _ 



include ir:lformation about behavioral or mental health servlces and treatment for alcohol ana drug abuse. 

This information may be disclosed to and u$ed by the, following individl,lal or organization: 

NAME: It da ~ /." " (I C, 0J ,//-::::,+cd--f! 

ADDRESS: Q(2(;'f I"=f'd< n+ r;p (bra ct'QO ::.:. 

I understand'that I have a right to revoke this authorizatiOh at, any time. I understand that if I revoke this 

authorization I must do so in writing and presant my written revocation to tile Health Informatior) Management 

Department. I understand that the revocation will not apply.to information that has already been released in 


or condition: "'L--:2- Q CJ 0f left blank, authorization will expire six (6) months from signing). 

I understand that authorizing the disclosure ofthis health information is voluntary. f'can refuse to sign this 

authorization. I need not sign this form in arderic assure treatment. I understand that I may inspect or copy the: 

information to be used ordisdosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure 

of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal or, 

state confidentiality niles. If I have questions about disclosure of my health information,! may contact the 

RHIT/designee ofthe ' , 

Signature 

~formiS 

, Social Security Number 

41/k;tA~~~- 

, Signature of Witness 

--.-' 

Date 


;2'-7-.. 0 7 

Date 

Slal.lalY (RCW 7a.02: .~CW 70.24.105; Ref!' 71.05.390) alld/or ftderol retula/ions (42 CFJ1.i'orl 2; 45 CFRPa,'( 164) prohibirdL

OFFENDER 1.0. OA·I.o.: 



Medicinal Use of Marijuana Verification. 

I i 

I 

i 

j 

I 

I, 


By state statute the Washington State Department of Corrections is charged with the responsibmty to supervise some 

. offenders after they have been convicted of a felony, The above named patient is currently under supervision by the 


behavior. Often iIIicitdrllg use is a contributing factor in an individual's criminaHty. Accordingly it's usual that the court or 


including mi:!rijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has 

been recommended. The below veriiication is to determine the legitimacy of their claim. Thank you in advance for your 

assistanc.e. If you have questions please fe",1 free to personally contactthe Medical Director of the Department at (360) 

725-8700. 

~. 


DNo· 

2. 

3. 

4. 

'5. 

6. 

Are you recommending medical marijuana for bis patient due to a diagnosis of Acquired 



b. If the answer to question 2a is "Yes", does he/she'have weight Joss 

Ar~ you recommending medical marijuana for this patient due to nausea and vomiting 


Dyes. 

DYes 

DYes 

DYes 

a. If the answer to question 3 is 'Yes", has the patient failed to respond to conventIonal 

DYes 


b. If the answer to question 3a is ''Yes'', Pleasefd~~c~hat those treatments Were (medication, pose, 

c. 

a. 

duration): , t1 ~. . . 

Wh,t;, th' pO"," ,,",,,,, of ch'mO!h_~ I V . 

If you answered "No· to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana J~.€- /..e..s...] Ccr ,;;-1 A- 

~ 

~ 

J6No 

Please provide evidence published in a peer-reviewed sCientific~Ub1iC tion to support the medicinal use of 

marijuana for this purpose n ,\.k'\ __ f> n . 

~ f\ ~~ " 


use of the oral synthetiC formulation of marijuana. If the Department autl10rizes this patient's 

use pf medical marijuana, will you be pre~cribing only the oral synthetic formulation 

The patient's accompanying Release of Information authorizes you to provide the 


the Department's Medica! Director of any changes in your answers above 

. . 

DOC 14-053 (Rev. 7131/08) 

0 Yes 

0 Yes 


~ 

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~ 

PDU-6655-3 000364

p0 ~ .(.%1>(" j I-/. 

Prescrtbe sName (Print) , 

)tLri_. _ 

License #: }if]) (}} 60 I 1(" 3 / . I License type: --=M:.!:...!1-..!D~· _________ _ 


2//5" e, iA/;;:) 5 iDYl 1f1tJ' Phone Number 

"':Sf' () t: C2 A€ Wq 99202- 

Prescriber: p!ease n~t!.lm"fh;s form and the p~tlent's Release of Information to: 


Health Servlces DiVision 


PO Box 41123 

. Olympia, INA 98504-2113 

J.,', 

52J1- 5"7D-.J-{8-j, 

§"o9-.2t-/ Z .. Y(02c./· 

To be filled out by boc Physician: 


(check one) lOis 0 is not . . 

consistent with DOC Policy. . . 

Pllyslcian's Name (Print) 

PhYSician's Signature 

Date 

.i· 

. Instructions to. DOC Physician: 

When form is complete::. 

1. Email your finding above to the Assistant-SecretarY for Community Corrections 

2. File this fo~m and the accompanying Release of Information in Uberty as a Community Gorrections Health Record .. 

State law (RCW 70.02j RCW 70.24.105; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 


permittee! by law. 

DOC 14.iJS3 (Rev. 7/31/08) DOC 380.200 

PDU-6655-3 000365



P.O. Box 41100 • Olympia, Washington 98504·1100 


, 

i 

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DeaiMr._ 

Your Medicinal Use of Marijuana request was received on December 23, 2008. Upon review by the 

Department of Corrections' Health Services physician, your request has been denied.' 

You may appeal this decision by sending your written request within 15 business days' of this letter, 



Community Correction,s Divi~ion 


P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional hlormation that was not .included with your original request. 

Appeals that do not contam new infomiation will be denied, You will receive a response to your 

~ppea1 request within 30 days of receipt. 

) 

Sincere 

.,/.' .... 

'~Ii- / .. 

~1~" Of ~ 

,/ Karen D~ s, Assistant Secretary I 

Community 'Corrections Division 

KD:md . 


Michael-Anclerson,8ommuni:ty.8orrections-0fficel"---------------------- 

Field File 



CBRMedical 



" Working Together for SAFE Communitj~s" 

PDU-6655-3000366

Documentation of Medical ,LI,uthorization to Possess Marijuana 


PATIENT NAME: -.,. __ 

DATE OF BIRTH: ---'--1-,-- 

I, . Dr. Mohammad H. Said , ;:Im'a physician licensed in the State of Washington 

. and I am treating the above patient for a terminal illness or a debilitating condition. as defined by 

RCW 69.51A.010. 

' 

I have advised the aboVe naiT,ec patier! about the potential risks and Qenefits of t"e medical use. 

of marijuana. I have assessed the abO'18 named patient's medical history and me,::ical cOhdition, 

It is my medical opirion thai the potential benefits of the medical use of marijuana may outweigh 

the health risks for this patier.t. . 

Physician Name: __-=D",r.c.;i'.:.,:1i;:,.of1",,' 

,8::.:(""c..:' ,.:..:m.;.:',":,o:cc.;r-c;':..;S",a::,:i..::.d_,--_wA License Number: ___"._1D_O_O_O_1_8_3_11_ 

Physician SignatLlre: 

U' r r~'~'Date: 

This recommendation expires on: 07/27i2009 

07/27/2008 

~ / ----~~~~~----- 


Under ",iashington law, tf1e use of rredical marijuana is now permissible for some patients 

with terminal or debilitating illnesses. The law regulating this (RCW 69.51 A) allows pr.ysicians 

to advise patients about the r.isks and benefits of the medical use of marijuana. . . 

The medical and scientific evidence'supporting the use of medical marijuana remains' 

controversiai in the medical community. Not all health 'care providers believe that medical 

marijuana is safe or effective and some providers feel that it is a da'ngerous drug. 

According to the Washington State law the benefits of medica! marijUana may inclUde 

treating nausea and vomiting from chemotherapy, AIDS wasting.syndrome, severe musc'e 

spasms from multiple sclerosis or other spasticity disorders, glaucoma, and some types of . 

intractable pain, 

, Some of the risks of medical marijuana may include possible long-term effects of the bra:r. i~, 

the areas of memory, coordination and cognition; impairment of tbe ability to drive or oper.ete , 

heavy machinery; respiratory damage; possible lung cancer: and physjC3~ or psychological 

dependence.. . 


As this patient's "60 day supply", as stipulated by RCW 69.51A(2)(b), I rec9X0men~;:4 ounqe.s 

of dried, cured"mariju8l')a and as many ptants as the patient feels necessary to maintain this "60 

day supply'. 





Spokane: 509-242·8624 

seattle: 206-774-6493 

Revised 7107 

PDU-6655-3 000367

MARIJUANA MEDICINE- 

EVAlUATtON CENTERS 

1512 Artesia Blvd. #120 

R~d"ndo Beach. C A 90278 

24 HOllf Verifibation 800.268.4420 

Or Verify Online at: w\\'\' •. mariiuanamedicine.com Click on "Dispensaries" Tab 

PHYSICIAN'S STATEMENT 

Health & Safety Code Section 11362.5 

·. 

This certifies that -.J 

was evaluated in my office for a medical condil:ion. 

which in my professional opinion, may benefit from the use of mediCal marijuana. I have ' 

discussed the potential risks and benefits of medical marijuana with the patient. I approve hislber 

use of marijuana as medicine. If my patient chooses to use marijuana as medicine, 1 will continue 

to monitor hislber medical COl1dition and to provide advice on hislber progress at least annually. 

In addition, I have informed my patient to infonn me of changes to said medical condition. I 

have inforrt1~d my patient not to· drive. opetate heavy machinery or engage in any activity that 

requires alertness while using medical marijuana. 

Pursuanno California HS 11362.5, Cornpassio~ate Use Act of 1996, also known as Prop 215, 

with this recommendation my patient is permitted possession of medical marijuana in quantities 

pun",",' to C~;fumi. HS 11362.77 ~. . 

Signed:. . 

Klen Tran, M.D. 

/" ,,/ 

. LJp'----'= 

Date of statement: ___-'O"-=5:....-1"-"6

!Fax 

CBR Medlcal, Inc 


.1 


From: me.JJS&1 @ C Bt 

o Urgent o For Review o Please ,Comment' 0 Pleas.a Reply 0 Please Recycle 

-Comments: 

CSR Medical, Inc, - 3115 E. Mission Ave, Spokane, Wa 992Q2 

Seattle Phone 206-774-6493 Fax 206-418-6659 Spokane Phone 509-2.42-8624 Fax 509-340-2710 

Tri-Cltles Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 3150-635-6464 Fax 206-418-6659 



exempt from disclosure under iilPplicable law. You are hereby notified that any dissemination, 

distribution, or duplication of this communication by someone other than the il1tended addressee 0\· its 

, deSignated agent is Strictly prohibited." .' 

A!llnformation is Protected Ul1der U.S. ~ederal Law 

PDU-6655-3 000369

~flor~1I 

.J''; ~. 

I l ~ATE OF WASHINGTON 


Medicinal Use of Marijuana Verification· 

OFFENDER \.0. OATA: 




Department Supervision is designed to help the offender avoid those environments or situations .that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court Or 

the Department of Corrections will. impose a condition of supervision that the offender not use, or possess illicit drugs, 


been recommended. The below veriiication is to determine the legitimacy of their claim. Thank you in advance for your 


725-8700.' .. 




a. If the answer to question 2 is "Yes", does hefshe ~ave anorexia 

b. If the a[lswer to question 2a Is "Yes", does he/she have weight loss 

3. Are you recommending medical marijuana for this patient due to nausea and vom,itlng 

. associated with cancer chemotherapy 

a. If the answer to question 3 is "Yes", has the P'ltient failed to respond to conventional 


~es 

DYes 

DYes 

DYes 

DYes 

DYes 


duration): N ( t~ 

.ONe' 

~ 

~. 

[:}M) 

~ 

~ 

4. 

c .. 

a. 

What is the planned schedule ~f ChemOtherapy/ .11. 

. r' r~ 

If y' au answered "No" to items 2 & 3~b ve what is the reason you are recommending medicinal use of 

, cl4.. 

marijuana , ';Jl. I A:- ~ f-.f!.-- vLJ fa 9, J • If 

~"V:r ;;r n . . 

Please provide evidence published in. a peer-reviewed scientific Pll~ication to support the medicinal use of 

mariJu~na for this purpose . f'--t. e... . M~~"'---' . 

5. 

6. 

While on community supervision ("parole") the Depa(tment of Corrections only authorizes the 



The patient's accompanying Release of Information authorizes you to provide the .. 


the Departmenfs Medical Director of any changes in your answers abovl'l' 

DYes 

tJ Yes 



PDU-6655-3 000370

Prescribe~s Name (Print) Prescriber's Signature 

1~-C-oV 

Date 

License #: lJ1 D b .0 D J ~ .3 / .1 License type: JY! 0 

Prescriber's Address "")/.1 2- c" g. 55:.0"7 4~/t" Phone Number 

SiD ~, 1/1.( ,0"'

-.." OFFENDER 1.0. O"TA: 

jDE~ . 

i ~} STATE OF WASHINGTON 




I, , h'!lreby authorize the use or disclosure of my health information 

as described below. The following individual or organization is authorized to make the disclosur~: 

NAME: 

ADDRESS:----------~--------------------------- 


Purpose for disclosure:. ___________________________ .....:. __________________________ _ 

I understand that the information in 'my health record may include information relating to sexually transmitted 


include information about behavioral or mental health . , . • • • , •• ., 

This information may be disclosed to and used by the 

NAME:' ____ -=-__ _ 

ADDRESS: _____________ __ 

I understand that I have a light to revoke this authoriZl 

authorization I must do so in writing and present my w 

Department. I understand that the revocation will not· 

response to this authorization. Unless otherwise revo 

or condition: 

(If I 

I understand that authorizing the disclosure of this he, 

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 unautl 

state confidentlality rules. If [ have questlons about dl 

RHtT/deslgnee of the facility: 

nent 

I in 

ate, event, 

)m signing). 

5 

opy the 

disclosure 

,deralor 

Signature of Patlent 

(Do not sign Ifform Is not complete) 

Date 


Social Security Number 

Date of Birth 

DOC Number 


Date 

Slata law (RCW 70.02; RCW70.24.1 05; nCW 1.05.390) .and/or federal regulatlans (42 CFR Pari 2; 45 CFR Part 1(4) prohibit di.



PATIENT NAME: __ _ DATE OF BIRTH: ~ 

, . 

I; . Dr. Mohammad H. Said , am a physician licensed in the State of Washington 

and I am t,aaUng the above patient for a terminal iIIness.or a debilitating condition as defined by 

ReIN 69.51A.010. . 

I have advised the above named patient about the potential risks and benefits of the medica! use' 

of marijuana . .I have assessed the above named patient's medical history and medical conditio!!. 

It is my medica! opinion that the potential benefits of the medical Lise of marijuana may outweigh 


Physician Name: __:::D~r. ..;.M:.!:o~h.!::a::.!.m:.:!m..:.:.:::'.a:::.d.!.H~ ...:::S:::a.!::id!.-..__ WA license Number: . MD00018311 




Under Washington law, the use of medical marijuana is now permissible for some'patients 

. with terminal or debilitating illnesses. The law regulating this (ReW 69.51A) allows physicians 

to advise' patients about the risks and benefits of the medical use of marijuana, 

The medical and scientific evidence supporting the. use of medical marijuana remains 



According to the Washington State law the benefits of medical marijuana' may include 

treating nausea and vomiting from chemofh~rapy, AIDS "'fasting syndrome: severe muscle 

spasms from multiple sclerosis or other spasticity disorders, glaucoma, and some types of 


Some of the risks of medical marijuana may include possible long-term effects of the brain in . 



dependence. . 

Recomme(ldation 

As this patient's "60 day supply", as stipulated by ReW 69.51A(2)(b), I recommend 24 oUl1ces 

of dried, cured marijuana and'as many plants as the patient feels necessary to maintain this "60 

day supply".. . 

'CBR Medical, Inc. 


3115 .E. Mission Ave 


Spokane: 509-242-8624 

Seattle: 206-774-6493 

Revised 7107 

PDU-6655-3 000373

GBN Medical lnc, 

No, 2826 p, 1/20 

I Fax 

CBR Medical, In~ 

31i5 E. Mission Ave 

Spokane, WA 992.02 

,FroirumeJl~§ C.Bt 

, ____ ~~~~~-U.-~~ • ..L,J,~---=n=a:.::.~e: -;:;"7 ',. dCS- C: if , __ _ 

o Urgent o ForR\lIv(ew a Please Comment 0 PIeas~ Reply D 'Please fU!:cycle 

·c;:omments: 

'----,.-_._--, --. 

C13R Medical, Inc,· 3116 =, MissIon Ave, spokane, INs. 99202 , 

Ssattle Phone 1.06-714-6493 Fax 206-1\18-6659 Spokane Phone 509-242.-8624 Fax 509.340-2710 

Tn-Cruss Phone 509-416-2267 Fax 509-340-2710 Vancouver Phone 360"635-6464 rax 206-418-6659 

, - 

CON}~IDENTIAUTY NOTICE: This communication is inttmdec\ for tl1e sole usa of the indiVidual and 

,entity to whon, 1\ is addressed, alld m&lY oontain information U;st is privilegocl, or confidential and 

eXGmpt from diiSClosure under appllcaplelaw, You are hereby notified that any dissemi!'12tion, 

distribution, or dupljcation of this communication by someone ather than the intenderj addr(3..

~ec. n.:2008 !:1:24PM CHR Med.i ca I Inc. No. 2826 P. 2/20 

OFFENDER LO. UAT,", 

S 

SiATE OF WASHINGTON 

CEPARTIIIIENT OF CORRECTlON.S 


Dear Prescriber; . 

By state statute the Washington Statl;l Department of Corrections is charged "~th the responsibility to supervise some' 


Department. Supervision is designed to help the' offender avoid those environments or situatioll$ that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. AccordIngly it's usual that the court or 

the Department of Corrections will impose a condition of SUpervision. that the offender not use. or possess illicit drugs, 


been recommended. The below verification is to determine the legitimacy of their claim. Th~'.Iflk you in advance fot your 

assistance. If you have questions please fee! free to personally contact the Medical Director of the Department at (360) 

. 725-8700. 

/ 


[i6Yes DNo' 



s. If Ule answer to question 2 is "Yes', does he/she have anorexia 

. . 


DYes 

DYes 

DYes 

3, Are you recommending medica! marijUana for this patient due to nausea and vomiting 


a. If the answer to question 3 is 'Yes" 1 has the patient failed to respond to c~nventional 


DYes 

Dyes 

b: . If the' answer to question 3a is 'yes', please describe what those treatments were (medication, dos.e, 

duration): ',J! V" . 

c. What is the planned schedule of chemotherapy ~ 

. . . fl/WY-' ." 

If vmJ answered "No· to items 2 &. 3 above, what is the reason you are recommending mediCinal use of 

marijuana . G&J1Y1 

. -...} fi- } . ,;7-'-X-, 

~ .' 

~ 

~ 

,~- 

f ~ ~t) R(i.. tV h 7, ~"I /1- 

a: Please provide evidence pLiblished in a peer-reviewed scientific pub ication to support the medicinal use of 

marijuana for .this purpose . 0 . A ..L I.. ..,., ~ . . . 

J -t e. r'-"'\-t"'"""'::.v- 

.~. 

I.~· 

5. 

6. 

While on community superVision ("parole") the Department of Correction!;) only authoriz~s the 

use of the oral synthetic formulation of marijuana. If the Department authori~es this patient's 

use of medical marijuana, will you be prescribing only the oral syn1tletic formulation 

The patient's accompanying Relees.a of InfO!matlon autho~e~ you to provide the • 

Departmenfwith current and future Information related to thIS !ssue. Do you agree to notify 


0 Yes 

DYes 

IlOC 14-053 (Rev. 7/31 lOS) 


; 

. ~ 

PDU-6655-3 000375

1-------' 

J 

Dec.23. 2008 5: 24PM CBR Medical inc. No. 2826 P. 3/2Q 

j 

.,' 

j 't' \' .~-.\ 

,:' to / 

I 

~-.:.~- /(~ 

~iJ --- C, •-0" \/ 

-- ~- .- I~ 

i 

ft 

Presoriber's Nim'le (printY'- '~,.' 

Preectlb$r'$ SlgnaIYI'$ ---------- Date --------- 

License #: ttl .[) _C.~::../.! l'i;"''7> I I License type: !YI i:)' 

';F [., t:r 

d 

£.4- - X 

Prescriber's Ad ress .J J I) C. ;, :/:'I~ . S 5. i.~·11 /,"1- ,-"t' Phone Number 

3r'[., t"~'/IU ".{}.

'.Vec,LJ, 2UUH ~:2JPM CBK Medical lnc, No, 2826· p, 4/20 


DEPAR11IIENT OF CORREC,.loNS 

AUTHORIZATION FOR DISCLOSURe 

OF HI;l:ALTH INFORMATION 

OF!'eNOER 1.0. CATA: 

I, , hereby authorize the use or disclosure of my health information 

as described below. The following individual or organiZatlon is authorized to make the disclosure: 

NAME: ______ _ 

ADDRESS:' _______ ...___._____ ~ __ 

The type and date(s) of informi;ltion to be used' or disclosed is as follows: 

-----.. ,-----:--- 

Purpose for dlscfosure:. __ _ 

------.... _----- 

I unde:rstandthat the infoimation in my health record may include information retating to sexually transmitted 

infections, Acquired Immunodeficiency syndrome (AIDS), or Human Immun()defil~lency Virus (HIV). It may also 

include informationabou~ benavioral or mental health '. , • , • • • •• ., • 

This information may be disclosed to and used by the 

NAME: ~ _________ _ 

ADDRl=SS: __ ~ ___ _ 

--_._,,---- 

! understand that I have a right to revoke this authoriz; 

authorization I must dO so in writing and present my w 

Department I undermand that the revocation will not 

response to this authorization. Unless otherwise revo 

or condition: 

...._ CIf I 

I understand that authori.:ing the disClosure of this he< 

authOrization. I need not sign thi!O form'in order to as. 

information to be m;ed or'disclosed, as provided in Cf 

of infOrmation carries With it the potentiql for an unautl 

state confidentiality rules. If I have questions about oi 

l/J ,~,Wf.i( 

/J h t>s~~« 

1- . -}./ 

D ,..', c.: -rr 

RHIT/designee oftha facility: _____ ~ ___ ._---,-___ ~ __ 

.. ";' 

, . ~; 

nent 

lin 

ate, event, 

)m signing). 

s 

opy the 

disclosure 

Idarslor 

, Signature of paUen! 

(Do not sign Iffonn is not completo) 

-_.,--- 

Date 

(Petfent 1tl complete) 

SocialSecurlly Number Oats ofBirih 

-~---- 

DOC Numbllr 

-~,.---- 

. Signature OfWilnoss ]').. 1 .. 

Slate law (Rew 70.02; RCW 7Q.24. W;; RCW 71.0S.J9Q)

Uec .. LJ. 2UUB ~:2!JPM No. 2826 P. ~/;lU 


for Medi.cal Purposes in Washington State 

PATIENT NAME: _.,.-_ 

DATEOFBIRTH:~ 



RCW 69.51A.010. 

j have Eldvis~d the above named patient abcut the potential risks and b~ilefits of the medical use 


ItJs my medical opinion that the potential benefits of the medical use of marijuana may outweigh 

the health risks for tI1is patient. . 

Physician Name: _--,O::!.f:,.J' M:;.!o:::.:h.!:;a::.!m.::..cm~ao.::d,-,-H~'..:;S:;::ae.::id:....... __ WA License Number: __..;..M_D_O_OO_1_B_3_11_ 

t=----+-!J+.·-(,fj-· 

PI1ysician .Signature: _. +./;u· ( _-:..... 

Gt....;.,-Al...,:.Q....:....._-_·_···_··,· 

I'. f. 

·This recommendation expires on: 07f27/2009 

Date: __;;;.;07~f2::.:7.;.:f2:.:0:..:.0;:..8___ 

Rislis and benefits of medical marijuana 

Under Washington law, the lise of medical marijuana is now permrssib[e for some patients 

with terminal 01' debilitating illnesses. The law regulating this (RCW69.51Aj allows physicians 

to advise patients about the risks and benefits of the medical use. of marijuana. . 

The medical and scientific evidence supporting the use of medical marijuana remaihs 

controversial in tM medical community. Notall Malttl care providers believe that medical 

marijuana is safe ot effective and some providers feel that it is a dangerous drug. 

Accorcling to tile Washington State·law the benefits of medical marijuana may include 

treating nausea and vomiting from chemotllerapy. AIDS wasting syndrome. severs. muscle 

spasms from multiple sclerosis or otller spasticity disorders, glaucoma, and some types of 


Some of the risks of mediCcd marijuana may include possible long-term effects of tile brain in 


heavy machinery; respiratory damage; possible lung cancer; and physical or psyc.l'Jological 

dependence. . 



of dried, cured marijuana and as many plants as the patient feels necessary to maintain this "60 

day swppl/'. . 

CBR Medical, Inc, 

Aclministrative Office 



Spokane: 509-242-8624 

Seattle: 206-774-6493 

Revised no·r 

PDU-6655-3 000378

~ .. 




Jfuluary 26, i009 

Mr._ 

Dear 

Your Medicinal Use of Ma.ri.juana request was. received on December 23,2008. Upon review by the 


you may appeal this decision by sending your written request within 15 business days of this letter, 



'.' CommunitY Corrections Division 

D~partment of Corrections 

P.O. Box 41126 

Olympia, WA 98504-1126 


Appeals that do not contain new info~ation will be denied. You will receive a response to your . 

appe~ request within 30 days of receipt. 

s;jv· .. n 

~~~~ 

./ Karen DW, Assistant S~cretary 


KD:md 

cc: JimKatlian, CommunItY CorrectlOns Supervlsor 

Michael Anderson, Community Corrections Officer 

Field File . 



CBRMedicaI 




t; rec)'clcd paper 

PDU-6655-3 000379

March 23, 2009 

STATE OF. WASHINGTON 




Dear Ms. 

I received your request to appeal th~ denial of your initial Medicinal Use of Marijuana 

Verification dated January I, 2009. 

You were approved on January 26,2009, to use marijuana medicinally, in accordanci;: with 

the law, while under the supervision of the Washington State Department ofCon'ections, My 

office contacted you to. inform you of this and I also contacted our Interstate Compact Unit 

and Field Administrator Donta Harper to re-initiate the process of having your supervision . 

transferred from Arizona to Washington State. I understand that since that time, your transfer 

was approved. 

By this letter, I am requesting that Com'munity Corrections Officer Michael Schemnitzer 

impose a DOC condition :that you not operate a motor vehicle while under the influence . 

. I would encourage you to continue to program in a positive manner, following the direction 

of your assigned CCO and your conditions of supervision. 


Community Conections Division 

KD:md 

cc: Donta Harper, Field Administrator . 

ToddJohnson,Connnum~~C~o~rr~e~c~ti~on~s~S~u~p-~e~~~i~so~r~ ______________________________ ~ ___ 

Michael Schemnitzer, Community Corrections Officer 

Tracy Gage, Interstate Compact Unit .. 

Field File __ 

. -0 ~"Cyclcd p"pcr .: 

" Working Together for SAFE Commun;fies" 

PDU-6655-3 000380


To: 


Attn: Karen Daniels - Assistant Secretary 

MS: 41126 

Olympia, WA 98504-1126 

From: ••••••••• 

Re: . 

Letter of Appeal 

Denial of Medical Marijuana while on Probation 

Thank you, for emailing the documents that you have on file.· ,I see that you did 

not receive my Medical Authorization to Possess Marijuana for Medical Purposes in 

Washington State or did you receive my prescription copy for Marillol. . 

I am including the following documentation to support my use of Medical 

Maijuana. 

A. Medical Authorization to Possess Marijuana for Medical Purposes in 

Washington State (copy) signed by 

Bethany Rolfe, SEA-MAR Community Health. Seattle, W A 

B. DOC form 14-053 (rev. 7/31/08). To include the use of Marino 1, synthetic 

formulation of Marijuana. signed by . 

Bethany Rolfe, SEA-MAR Coinmunity Health. Seattle, WA 

C. Marinol Prescription (copy) dated 8-12-08 

Bethany Rolf~, SEA-MAR Community Health. Seattle, WA 

D. Marinol Prescription (copy) dated 01-05-09 re:fi11 

Bethany Rolfe, SEA-MAR Co~unity Health. Seattle, WA 

E. Documentation of Medical Authorization to Posess Marijuana for Medical 

Purposes in Washington State. 

Dr. Karen HIDilton 

Dated: September 20th, 2008 (expires September 20th 2009) 

F. Copy of Aut.1torization Card (pocket size)(front) 

Dr. Karen Hamilton 

G. Copy Card Back 

H. Marinol Prescription (copy) dated 09-20-08 

Dr. Karen Hamilton 

Dr. Hamilton declined to fill out the DOC form ~ 1108). Tfyou 

should have any further questions, please contact me at ____ 

I will have more documentation from more docotors as I will be having a total 

knee replacement in the next couple of months at theUniversity of Washington. 

I look forward to hear;ing from you. 

PDU-6655-3000381

t. 

Page 1 ofl 

..,,-;...-.... -. .... ~ 

. ·~,..{;/'·'"·";""'-·"'j"~j".o··.,.\'''''.,.).'"''c,"'' 

",-,-.:," 

i.,,", 

c· 

f.: :.' . i: ~ 

I:, .':' .' Pint Qualifyiimg ·P-atile.n.t~#..N3ime: 

ort~i.onto 

.. ashmgton State ~ 

~ .. 

1. '. 

[~~: :;", ' 

r .:' .:. ": temrinal illness or ~:~ebil¥ting coiidltio~~'as:defi:iied' m,. RCW 69.51AOIO. I have advised the . 

... 1 am a physician lice~d-,k the State of.W §Shin.gt~.I",~.treating tb.~bove named patient for a 

t. '.": .. ", above named pa"tiert(abo"iilJhe potential risks and benefits offue medicif use of marijuana. I have 

aSsessed the above name

~1'lCIrs"l'oc. 

...... \ 

f ~ STATE OF WASHINGTON 

;i:1 = OEPARTMENT OF CORRECTIONS 


OFFENOER I.D. DATA: 





behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's· usual that the court or 

th.e Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, 


been recommended. The below verification is to determine the legitimacy of their .claim. Thank you in advance for your . 

assistance. If you have' questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. 




a. If the answer to question 2 is ''Yes·, does he/she have anorexia 


'C2(Ves 

DVes 

DVes 

DVes' 

DNo 

[2I"No 

lcl'No 

~o 


associated with Cancer chemotherapy 

DVes 

a. If the answer to question 3 is "Ves", has the patient failed to respond to conventional 

DVes 


b. If the answer to question ~a is "Ves', please desqribe what those treatments were (medication, dose, 

duration): . 

~o 

DNo 


4. If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use of 

marijuana 'See.. \ e..~\ex- \)~6 "'""V.~ .;coi -.t;:-ro('l"\, ~r _ 'B,u \~ ... L.\."ci.c..- ~l0 (,;cl.5i. A . 

a. Please provide evidence published in a peer-reviewed scientific publication t6 'support the medicinal use of 




use of medical marijuana, will you be prescribing only the oral synthetic formulation . 




~C\..\\

'I 

! 

I 

i 

Prescriber's N~rint) , 

License #: to 1 ~ - I \ 3 (0 0 ~ LiceRse type: NP I 


Phone Number 

Prescriber: please return this form and the patient's Release of Information to:' 

iv1edicai Director 



POBox 41123 

Olympia, WA 98504-2113 ' 

001 Mar Community IIealth Centers 

~, White Center Medica! 

,~=, 9650 J5lli Ave &W #100 

'ii' &ea.ttle, WA 981C6 

('2C6) 965 10c0 Vax it ~) 9ffj 1001 

To be filled out by DOC Physicictn: 


(check one) I Dis 0 is not ' 

consistent with DOC Policy., 

Physician's Name (Print) Physician's Signature Date 



1. Email your finding above to the Assis~ant Secretary for Community Corrections 

2, File this f~rm and the accompanying Release of Information in Liberty asa Community Corrections Health Record. 

State law (RCW 70.02; RCW 70.24.105; RCW 71,05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 



' 

DOC 14-053 (Rev, 7/31/08) DOC 380,200 &3 

PDU-6655-3 000384

·....._._......._....._._--_....._......_._._------- 

DocClmentation of Medical Authorization to Possess Marijuana 

for Medical Purposes in yvashington State 

PATIENT NAME: DATE OF BIRTH: ~ 

I, Karen Hamilton, am a physician licensed in the State of Washington and f am treating the 

above patient for a terminal iflness or a debilitating condition as defined by RCW 69.51A.010. 

! have advised the above named patient about the potential risks and benefits of the medical use 

of marijuana. I have assessed the above named patient's medical history and mkdical condition. 


. the health risks for this patient. 

Physician Name: Karen Hamifton, MO 

WA License Number: MOOOO'34688 

Physician Signature: -LJK~fb,~==-.J.L~. ===::----=-_..:.... ___ Date:· September 20, 2008 

This recommendation expires on: September 20,2009 



with tenminal or debilitating illnesses. The law regulating this (RCW 69.51 A) allows physicians 




mariju~ma is safe or effective and some providers feel that it is a dangerous drug. 

According to the Washington State law the bene"fits of medical marijuana may include 


spasms from multiple sclerosis or other spastiCity disorders, glaucoma, and some types of . 


Some of the risks of medical marijuana may include possible long-term effects of the brain in, 



dependence. 

R€!commendation 


-------,ohIrted-;-cored ltJarijoafia-an·d-a5l11c'fiiVPlarmnl1:nl'f~t1enneels necessary to marntam tf.iTs"6'.,.,O,--- 

day supply", 

Revised 7/07 

PDU-6655-3 000385

· I, Karen Hamilton, am a physiCian licensed in the Slate of 

Washington. I am treating tlTe above named patient for a terminal 

illness or a debilitaling. conditions as defined by RCW 6!t51A. I have 

advisee! this patient about the potential risks and benefits of the use of 

medical marijuana.' I have assessed, this patienfs medical history and 

medical condition. ltis my' medical opinion' that the potential benefits 

of the medicaf. use of marijuana may outweigh the health risks for this 

qualifying patient 

Issued: 09-2.0-08 . lfA 

Expires: 09-20-09 a-,i,.; (fih ,.1]) 

, MD - MD00034688 

PDU-6655-3 000386 

f

,,~ , 

·f 

Smith, Sherri K. (DOC) 

From:' 

Sent: 


Friday, August 01, 2008 7:35 AM . 

To: Praven, Jeremy M. (DOC); Johnson, Todd D. (DOC); Harper, Donta S. (DOC); Fiala, Anne L. 


Cc: 

Subject: 

Cowan, 

. Medical 

The offender's request for medical marijuana use has been denied by Dr. Hammond, Director of Medical Services. 

Sherri Smith, Executive Assistant to 

. Karen Daniels, Assi~tant Secretary . 


MS: 41126 . 


Olympia, WA 98504-1126 

Phone: 360·725-8847 

Even if you're on the right track, you'll get run'over if you j1;lst sit there. ~Will Rogers 

1 

PDU-6655-3 000387


From: 


Sent: Wednesday, 23,200812:35 PM 

To: 

Daniels 

S.ubject: 

M Denial 

Karen, 

I denied a request for authorization for medical marijuana use by this offender. 

Steve Hammond 





POS 41123 

Tumwater, WA 98504-1.123 

360-725-8700 

1 

PDU-6655-3 000388

i •. 

. . 




. Washington State Depart;ment of Corrections 

PO Box 41123 

Ol~pia, WA 98504-2113 


I have reviewed, thi~ verificati~n. fo~ fuid that use of medical m.arijuana by this patient 

(check one) lOis ~~t·~ . . 

consis,r with DO~ Policy. .... I . 

. (~8k~~tM- (~~~ ·.frJ~ 


Ph~an's Signature 



1. Email your finding above to the Assistant Secretary for Community Corrections , 

2. F~Ab~1gr~~~~~.MPE!1ll!1!:l'~&r.!JE~JiJLfJJ,~i~~~~1Qv~liY!l;l1fM:~QQjggr.Q.l5:m~~ffill~~&1d~ 

. Sta~e law (RCW 70.02; RCW 70.24. !O5: RCW 7 U)5.390) ancl/orlederal regulatiolis (42 CFR ParI 2: 45 CFR Par! 164) prohibii disclosure qf 

this iqformalioll withoulthe specific written consent qfthe person 10 whom it perlains. or as ollierwise pel'milled by law. 

DOC 14-053 (05/16/08) . DOC 380.200 

PDU-6655-3 000389






c------' hereby authorize the use or disclosure of my health information 

ual or organization.is authorized to make the·disclosure: 

NAME: Se.q '\'(\:z --r ~ \'\'.'N"'\\ 11\,,: ~\/ ~j'c1e K S 

ADDRESS: Cir0-5(,) \5!b-.-k\rt_ Sou,) 18u·,+e..... LnO 

Se..g-h \e LC) f\ Cjq, lUe ) . 


Purpose for disclosure:---,M~A-__'--__________ ~----'------'--·I),·~· ~_ 



.include information about behavioral or mental health services and treatment for alcohol and drug abuse. 

This information may b.e disclosed to and used by ·the following individual or organization: 

NAME: . J){Po.v- I- !"YI.£ rd- ct{ C ¢IV" vc.i.:hUYH 

ADDRESS: _________________ ~--~--------- 



Department. I understand that the revocation will not apply to information that has already been released in . 


or condition: 

(if left blank, authorization will expire six (6) months from signing). 



information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure" 

of information carries with it the potential for an unauthorized redisclosure and may not be protected "by federal or 

state confidentiality rules. If I have questions about disclosure of my health information, I may contact the 

RH.lT/designee of the faci! 

• ~ ~ I J.:1 • 

~ 

•. I. .. . rm is not complete) 

'] .. 

\L\-o~ 

Date 


Date 

Slare law (RCW 70.02; RCW 7O.24.11!5: RCW 71.05.390) {",d/or federal regulatian.,· (47 CFR Parr 2: 45 CFR Purl 164) praMbir disclosure 

. a/this injbrmation ;"V!I/UJlII The specific wriUen consent oJthe person to llll1O111 it pertains, or CI.~ tJchen1'ise permiaed hy law. 

DOC 13.{)35 (05/1912008) POL" • DOC 380.200 DOC 600.020 DOC 640.0~0 DOC 670.020 LEGAL 

PDU-6655-3 000390

July 14,2008 

To: 

Re: 




PO Box 41123 . 

Olympia, WA 98504-2113' 

·lIJ!I!!J!!!ns ii/ __ 


I __ BETHANY ROLFE 

am currentIytreating the above named patient for the 

following conditions as defined in RCW69.5LOlO. 

(b) . Intractable pain, limited for the purpose of this chapter to mean pain unrelieved by 

standard medical treatments and medications. ' . 

Patient also has a history ~f.the following conditio~: 

a) Fibromyalgia 

b) Allergic Rhinitis 

c) IBS with bowel incontinence 

d) History of leucopenia 

e) OA, Right knee, total replacement August 2002 

f) Partial hysterectomy due to fibroid tumors 

g) Depression 

h) AnxietylPanic attacks 

i) Carpal Tunnel 

j) , Migraine headaches 

k) Restless Leg Syndrome 

1) High Blood Pressure 

m) Fibroid tumors throughout body 

n) , Left knee, worn out, recommended replacement fall 2008 or spring 2009 

0) Insomnia, hard to fall asleep, staying asleep, falling back to sleep 

,.' 

Patient has drug allergiesfmtolerance to the following medicationS: 

1. Erythrom'ycin causing difficulty breathing/shortness of breath 

2, ' Demerol causing nausea and vomiting , 

3. VicodID causing nausea and vomiting 

4. Percocet causing nausea and vomiting 

5. Penicillin causing hives 

6. Morphine. causing blister, rash, itching 

7. Sulfa-base drugs causing GI upset, hives and itching 

8. Dococycline causingL.:G:;::I:...:u::.tp::::se::;t=--:-_-:-:--__________________ _ 

----------,.9;-.----;axycodone causing nausea and vomiting 

10. ' Paper Tape causing rash and itching 

I have advised the above named patient about the potential risks and benefits of the medical Use of 

Marijuana. I have assessed the patient's medical history and medical conditions. It is my medical 

opinion that the potential benefits of the use of marijuana may outweigh the health risks for thi,s 

patient. ' 

bL&1A-~ JfkL!6 

Signature of~hysician:--____ _r_I__--+~---- 

Bethany RoIfe~ 1596133 

Tel: 206965 1000 

PDU-6655-3 000391


From: 

Sent: 

To: 

Subject: 


Monday, February 23, 2009 10;43 AM 

.Checo 

1 

Ana V. iiil(evey, Mac B. (DOC) 

We received an appeal to Mr .••• lmedicinal marjiuana denial from his physician. 


appear in the next 30 days. 


Thank you! 


Executive Assistant to . 





. (360) 725-8796 


1 

PDU-6655-3 000392


From: 

Sent: 

To: 

Cc: 

Subject: 

H

Page 1 of3 

Distefano, Monica J. (COC) 

From: Hammond, G. Steven (DOC) 

Sent: Monday, November 03,200810:58 PM 

To: Checo, Ana V. (DOC); Daniels, Karen R. (DOC); Distefano, Monica J. (DOC) 

Subject: RE: Medical Marijuana . 

OK. great, Ana, I'I! be looking for it. 

Steve Hammond 

From: Checo, Ana V. (DOC) 

Sent: Friday, October 31,20088:49 AM 

To: Hammond, G. Steven (DOC); Daniels, Karen R. (Do.C); Distefano, Monica J. (DOC) 

.Subject: RE: Medical Marijuana 

I'll have Mr.~ubmit a completed form from his doctor. 

Ana V. Checo . 

Community Corrections Officer .. 

Federal WaY' Field Office 

606 West Gowe St 

Kent, WA 98032 

MS: TS-71 

253-372-6463 office 

253-372-6184 fax 

From: Hammond, G. Steven (PaC) 

Sent: Friday, October 31,20088;43 AM 

To: Checo, Ana V. (DOC); Daniels, Karen R.,(DOC); Distefano, Mon!ca J. (DOC) 

Subject: RE: Medical Marijuana . 

I don't have that case in my files. Also, if the request was made in March or April, that is bef9re we had set our 

policy about authorizing use of medical marijuana. 

Monica or Karen, do you' have information on this case I would be happy to review it if you do. If indeed the 

request was made prior to our setting the policy and developing the information form, probably we need to have 

Mr. have the form completed by his doctor. . '. 

Thanks, 

Steve Hammond 

From: Checo, Ana V. CDOC) 

Sent: Friday, October 31, 2008 8:27 AM 

To: Hammond, G. Steven (DOC) 

Subject: RE: Medical Marijuana 

That Offenders information would be helpful, duh! 

His name is 

His previous ceo sent information to K. Daniels back in March or April 

of 2008. Should yciuneed any further information I will gladly send it· to you. . 

4/13/2009 

PDU-6655-3 000394

Page 2.of3 

Thanks, 

Ana V. Checo' 


Federal Way Field Office 



MS: TB-71 

253-372-6463 office 

253-372-6184 fax 

From: Hammond, G. Steven eDOC) . 


To: Checo, Ana V. eDOC) 


I'm not sure what case you're talking about. 

GSH 


.. Sent: Wednesday, October 29,20089:06 AM 

To: Hammond, G. Steven eDOC) 


I was wondering if you have had the opportunity to look at the case 

Ana V. Checo 


Federal w.ay Field Office 


.... Kent, WA 98032 

MS: TB-71 

253-372-6463 office 

253-372-6184 fax 

-~.,~"~-= ...... = ........ =--.. ~==== ....-.. ~-.. == .. = ........... =- .... = .... ==== .. -= ..-.. = .. = ....-.. = .. --=--=----=--=,=---= ..---~~+===.""",;,,==-==== = .. 


Sent: Wednesday, October 01, 2008 5:41 PM 

To: Stern, Marc F. 'Dir Hlth Svc' (DOC)i Checo, Ana V. (DOC) 

Cc: Daniels, Karen R. (DOC) . 

.. -"~-~=~~ 

---~Subject:--RE:_Medical-MarijtJana-----,--------------.......,.------------ 

I'm happy to have a look at it, Ana, If you" can send the name and #, I can see if I have a record of having 

reviewed it previously. .. 

Steve Hammond 

From: Stern, Marc F. 'Dir Hlth Svc' eDOC) 


4/13/2009 

PDU-6655-3 000395

Page 3 of3 

To: Checo, Ana V. (DOC), 

Cc: Daniels, Karen R. (DOC); Hammond, G. Steven (DOC) 


Ana, 

No bother, but this is all governed by policy. It sounds like something unusual may have happened in this case 

(outside of policy) if the paperwork was forwarded to Karen Daniels il1stead of the Medical Director. My 

suggestion is to send an email to the medical director (Dr. G. Steve Hammond) and Karen, with the name of the 

patient, and see if either of them has seen it yet. 

' 

Marc 

From: Checo, Ana VI (DOC) , 


To: Stern, Marc F. 'Dit Hlth Svc' (DOC) 

Subject: Medical Marijuana 

I have assumed supervision of a case where the offender was prescribed medica! marijuana on 3/24/08. The 

previous ceo has sent the necessary documents to Ms. Daniels. ,I was informed, not sure if correct, that the 

case needs to be reviewed by you. If that is the case can you let me know what information you need, P's Dr's 

name and number, etc. so this issue can be resolved. 

If your not involved, sorry'for any inconvenience: 

Thanks, 

Ana V. Checo 

Community Corrections Officer, 

Federal Way Field Office ' 


Kent, WA 98032' 

MS: TB-71 

.253-372-6463 office 

253-372-6184 fax 

4/13/2009 

PDU-6655-3000396

Page 1 of3 


From: 

Sent: 

To: 

Checo, Ana V. (DOC) 

Friday, October 31, 2008 8:49 AM 

Hammond, G. Steven (DOC); Daniels, Karen R. (DOC); Distefano, Monica J. (DOC) 


I'll have Mr._ submit a completed form from his doc~or. 

Ana V. Checo 

Community 'Corrections Officer 

Federal Way Field Office 



MS: TB-71 

253-372-6463 office 

253-372-61B4 fax 


Sent: Friday, October 31, 2008 8:43 AM . 

To: Checo, Ana V. (DOC); Daniels, Karen R. (DOC); Distefano, Monica J. (DOC) 


I don't have that case in my files. Also, if the request was made in Marqh or April, that is before we had set our 

policy about authorizing use of medical marijuana. 

Monica or Karen, do you' have information on this case I would be happy to review it if you do. If indeed the 

request was made prior to our setting the policy and developing the information form, probably we need to have 

Mr. May tum have the form completedby his doCtor. . .' 

Thanks, 

Steve. Hammond 



To:. Hammond, G. Steven (DOC) 

Subject: RE: Medical Martluana 

That Offenders information would be helpful, dull! 

His name is 

. His previous CCO sent information to K. Daniels back in March or April 

___,o.i2QQ8.._Sho.ulcLy:o.u..oe.e.cLao.)Lrur.tbeur.ifor.r.natio.r.LLwilLgladL)Lseo.cLlLtCLyou . 

Thanks, 

Ana" V. Checo 


Federal Way Field Office' 

606 West Gowe 'St 


MS: TB-71 

4/13/2009 

PDU-6655-3 000397

PageZ of3 

. 253-372-6463 office 

253-372-6184 fax 


Sent: Friday, October 31, 20088:14 AM 

To: Checo, Ana V. (DOC) 


I'm not sure what case you're talking about. 

GSH 

From: Checo, Ana V. eDOC) 

Sent: Wednesday, October 29,20089:06 AM. 

TQ: Hammond, G. Steven (DOC) - 


I was wondering if you have had the opportunity to look at the case 

Ana V. Checo .. 


Federal Way Field Offi~e 


Kent,WA 98032 

MS: TB-71 

253-372-6463 office 

253-372-6184 fax 

. From: Hammond, G. Steven (DOC) 

Sent: Wednesday, October 01,20085:41 PM 

To: Stern, Marc F. 'Dir Hlth Svc' eDOC); Checo, Ana V. (DOC) 

Cc: Daniels, Karen R. (DOC) . 


I'm happy to have a look at it, Ana. If you can send the name and #, I can see if I have a record of having 

reviewed it previously. 

Steve Hammond 

From: Stern, Marc F. 'Dir Hlth Svc' (DOC) 


---TTa:-Chl~"C"o7",lI;h"i:rV':-(DOC)\--'-:'----'-· --------------------,-.----- 

Cc: Daniels, Karen R. (DOC); Hammond, G. Steven· eDOC) 


Aria, 

No bother, but this is all governed by policy. It sounds like something unusual may have happened in this case 

(outside of policy) if the paperwork was forwarded'to Karen Daniels instead of the Medical Director. My 

suggestion is to send an email to the medical director (Dr. G. $teve Hammond) and Karen, with the name of the 

patient, and see if either of them has seen it yet. . 

Marc 

4/13/2009 

PDU-6655-3000398

Page 3 of3 



To: Stern, Marc F. 'Dir Hlth Svc' (DOC) 

Subject: Medical Marijuana 

I have assumed supervision of a case. where the offender was prescribed medical marijuana on 3/24/08. The 

previous eeo has sent the necessary documents to Ms. Daniels. I was informed, not sure if correct, that the 

case needs to be reviewed by you. If that is the case can you let me know what information you need, P's Dr's 

name and number, etc. so this issue can be resolved. 

If your not involved, sorry for any inconvenience. 

Thanks, 

Ana V. Checo 


Federal Way Field ~ffice 



MS: TB-71 

25·3-372-6463 office 

253-372-6184 fax 

4/13/2009 

PDU-6655-3 000399

Jan. ::lU. :.1UU9 1 L: U~PM ~cott L. Havsy, OO,OMPM No. 9134 .P,. 1 

", 

Office of the Deputy Secretary 


STATE Or-WASHINGTON 



FEB 0 Z 2009 


_'""(!\ r:-- l"'4 

- ~1! T ~ ~r~·t ~~~ ~ ; 

. , 

JAN 2. 9 2ntt§ 

':: 

i;. 

Federal Way, W 1:- 98023 

Dear Mr._ 

Your Medicinal Use of Marijuana request was received on January 7, 2009, Upon reviewby the 

Department of Qorrections' Health Services physician, yom request has been denied. 

You may appeal this decision by sending yom written request within 1S business days of this lett , 

which is on or before February 16,2009. Please send your request to the ess below: 



Department of Con'ections . 

P.O. Bo:.t:41126 

Olynipia 7 WA 9850~ll26 

Your request must provide additional informatiQIi. that was not included with y original request. 

Appeals that do not contain new information will be denied; You will receive a response to your 

appeal reque~ wi;thin 30 days of.receipt. .' . .' . 

KD:lhd 

cc: MiiCPevey, Commuruty CorrectlOns Supervisor 

Ana Checo, Community Corrections Officer 

Field File 


Scott L. Havsy, DO, DAAPM 

3716 Pacific Ave., Stiite E 

Tacoma, WA 98418 

II Working Together/or SAFE Communltit;JS" 

PDU-6655-3 000400

Jan. 30. 2009 12:05PM Scott L. Havsy, DO,DAAPM No.,9734 P; 2 

KAf1u{~AA; e,\~\;+55J~~ jccfe:k.r~ 

t-~11t.:~~~~, 0 ;."Slo/{" ~~/ ~ r /1M..dr . I- L 

~ - D III 

. ~:::--I- 4A ~p~~ ~t. ~iD.e Ih- J'L'f'(IP'iA JMeJ 

,0ML'Jw,,-~«1,/,'2.0octf.=r: W6IJlc.l1,le.. Gl-tS ~eJl ~::.. lYL'-C Dochr 

',Dr, .:sc..orr \-tF\IJ~'i +u i~ ~~J'''.s~, FtfPeAI, ~ cle~'5:or.( ~A-t-. '\' 

" t:J~.s fY\Ptd~ ,t');-l fYl.:i, 1'Y\,~tl;U'!-l U,~,t. b~, ~,~ (/\edl'ur/"iMt: \J,O.l, f,bt,Ce.,\ 

5-\-¥:rK') '~\- .\~ ~;, \\\,w\'u\ ~tI'r- fl'\.L ~() be.. r(~c..;'Jbe.& i1lLJ,l4k~1..f 

~tfl]'Y). c.. \i'e.e.~~J.. Q~Je,;tlt-\ \,1' ~ttv'(., ,u.\I\'\t'l)\- ioe.~ Dr-{ ~\ mc.J,Ot-kfJ)(' 

~r-: p... 'ie~f" M~ dCC-~r uJOv'\~ \\t~ \~ ,,\D~ fravcl- ~'.- ~ ~fe*\' 

~;'\~' ~ ,3'0 'C.DtJ\o.., ~o0 FttASc... 5C.\~v'i'., a... hW:>l]1;:or 

/1 W~~~ Br~,:b~. A~N.'l. . 

~'h ", 'tOJ ~ ,~nVv--h'(Y\:t: 

;'tt t-l-,'s ' 

- O()~ J±-' 

'-:::::;z ---- : 

PDU-6655-3 000401


STATE OFWASHINGTON 



ceo: 

ber 

To be filled out by Prescriber: . 




Department. Supervision is designed to' help the offender avoid those environments or situations that lead to their criminal 


the Department of Corrections will impose a condition of supervision that the offender. not use, or possess illicit drugs, 

including marijuana. This offender has ciaimed that they have a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your, 

. assistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. 

1. Is this patient 'under your care ~ .. D~o 



DVes ~ 

a. If the answer to question 2 is "Yes", does he/sbe have anorexia DVes. DNo 

b. If the answer to question 2a i~ "Ves·, does he/she have weight loss DVes DNo 


DVes 

associated wit~ cancer chemotherapy 

~ 

a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional 0 Ves 0 No 

antiemetic treatments ' . 

b. If the answer to question 3a is "Ves·, please describe what those treatments were (medication, dose, 

duration): . 


4. 

5. 

If you answered "No" to items 2 & 3 above, what is the reason you are recomme'nding medicinal use of 

marijuana r / -iV·P Gr.- /I,..,..p " ' , 

1f' . 2:>/ tIfi~ '- .. 


marijuana for this purpose'"!' r d #. 

, ~~~ , J.- 1~ r=1~-. - - . 

f~. E'/ ,.~ . 

~_v ~ -.L,. .. .v( ~ -tfA". /"i -cJR.r-- ~ fo ~ I J.. #t~, 

Whirs on ;mmunity supervision 'parole") tlie Department of Cor ctiorTs'onlyauthorize tlie 

...... r-7.. 

use of the oral synthetic formulation of marijuana. If the Department authorizes this patl 1's 0 Ves f~O 

use of medical marijuana,'",:,i11 you be prescribing only the oral synthetic formulation 




OVes' ~. 


PDU-6655-3000402

License #: 




PO Box41123· 

Olympia, WA 98504-2113 


I have reviewed this verification form.fi:rtclfind that use of medical marijuana by this patient 

(check one) LOis ~ is not . .. . 

consistent with DOC Policy. . ."-. . 

II'. ... 817 ~ 






2. File this form and the accompanying Relea$e of Information in Liberty as a Community Corrections Health Record. 

Date 

. ··/t/· 

.. 

.;:1/· 

- r 

fe~ ~ ~, I 

State law (RCW 70.02; RCW 70.24.1 05; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infomiation without the specific written consent of the person to whom it pertains, or as otherwise 



PDU-6655-3000403

Scott L. Havsy, DO, DAApM 

-Board Certified in Pain Management 

American Academy o/Pain Management 

www.managedpain.com ' 

drhavsv@comcast.net 

February 9, 2009 . 


State of Washington 


PO Box 41126 ' ' 

Olympia, WA 98504-1126 

Dear Ms. Daniels: 

In the future, pleas'e do not forward me requests from the Department of Correction dealing with the approval or, 

denial of the use of medical marijuana. If you bother reading the Statute RCW 69.51A, there is no provision for ' 

the Department of Corrections or anyone who is under their auspices to be denied medical marijuana and 

treated separately if the physician feels that the patient's condition may be of benefit regarding the use of , 

medical marijuana. 

Your Department narrowly construes the statute, which I believe is unconstitutional and I am sure in the future 

this matter will be dealt within the court system. 

' 

'Mr._suffers from multiple herniated'discs in the cervical spine with'bilat~ral carpal tunnel syndrome 

and it is my opinion that medical marijuana is a medical necessity. I prefer him tO,be on anon addicting 

, substance as opposed to opioids for chronic pain. In my practice of addiction medicine, narcotics are more of a 

problem than marijuana. The Department of Corrections does not have any right to deny or approve the use of 

medical marijual"la if a li«ensed physician in the State of Washington feels that the patient, pursuant to the 

statute, may-get benefit from the use of marijuana. 

I would appreciate you having your legal counsel, ot staff physician who denies the use of marijuana contact me 

on this matter so I can intellectually explain this situation to them. Also please forward to me all information 1 

that you currently rely on to approve or deny the use of medical marijuana for patients who are under the 

--auspiees-0:f-the-QQG"..... ---------------- 

,.-........ .. 

, 1 Information includes RCW's, WAC's, memorandum, medical treatises, studies, internal memo's on any format. 

3716 Pacific Ave. Suite E 253-473-2663 1 


(F)253~473~0545 

PDU-6655-3 000404

SLH:bw 

Scott L. Havsy, DO, DAAPM' 


American Academy of Pain Management 

www.managedpain.com 

drhavsv@comcast.net 

cc: Governor Christine Gregoire 

Office of the Governor 

--416-14th-Avel'll:1e-S-W;·-S.uite~2QO· .....----... 

PO Box 40002 


----_._---_...-._------_._---_.._-----'-.._--._-- 

Douglass Hyatt, Attorney 

3716 Pacific Ave. Suite E . 

. Tacoma, WA98418 

253-473-2663 

00253-473-0545 

2 

PDU-6655-3 000405


From: 

Sent: 

To: 

Subject: 


Monday, February 23, 2009 10:43 AM 

_pevey, Mac B. (DOC) 

We received an appeal to Mr.~edicinar marjiuana deni~1 from his physician. 




Thank you! 







(360)725-8796 


1 

PDU-6655-3 000406




Janumy26,2009 

Mr._ 

Dear 

023 

Your Medicinal USe of Mar'Jjuana requestwas received on January 7, 2009. Upon review by the 

Department of Corrections' Health· Services physician; your request has been denied. .. 

You may appeal this decision by sending your written request withii115 business days of this letter, 

which is on· or before February 16, 2009. Please send your request to the address below: 




P.O. Box 41126 . 

Olympia, WA 98504-1126 


. Appeals that 40 not contain new information will be denied. You will receive a responSe to your 


. KD:md 

cc: Mac Pevey, Community Corrections Supervisor 

. Ana Checo, Community Corrections Officer 

Field File 


Scott L. Havsy, DO, DAAPM 

3716 Pacific Ave., Suite E 

Tacoma, WA 98418 . 


-0 .rc!:cycled paper 

PDU-6655-3 000407


From: 

Sent: 

To: 

Cc: 

Subject: 


Monday, January 12, 2009 3:20 PM 

Distefano, Monica J. (D'OC); Daniels, Karen R. (DOC) 


M Request 

Mr. Maytum's request for medical marijuana does not meet our criteria for medical necessity. 





POB 41123 


360-725-8700 

". 

1 

PDU-6655-3 000408

ST-ATE OF WASHINGTON 



February 20,2009 

Tacoma, W A 98445 

DearMr.'_ 


Department of C~rrections' Health SerVices physician, your request has been denied . 

. You may appeal this decision by sending your written request within'IS business days of this letter, 

which is on or before March 16,2009, Please send your request to the address below: 




P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must' provide additional information that was not included with your original request.· 


appeal request within 30 days of rec~ipt. 

Sincerely, 

.~ 



KD:md 

----00-:--Rebert-Pearson,Gomfl1unity-G01'l.'eeti0I'1S-Sl:l:peFV·isol''----------------'------- 

Danny Avent, Community Con-ections Officer . 

Field File_ 

Physician'S Office: . 

Scott Havsy, DO 

3716 Pacific Ave., Ste .. E 



0. recycled. paper 

PDU-6655-3 000409


From: 

Sent: 

To: " 

Subject: 


Friday, February 06, 2009 8:24 AM 

_ . OC); Daniels, Karen R. (DOC) 

, M Request 

request for authorization for use of medical marijuana does not meet criteria fdr medical necessity. 

1 

PDU-6655-3 000410


i 

_.J 

STATE OF WASHINGTON' 










including marijuana. This offender has claimed that they have a condition for which th~ medicinal use of marijuana has 



725-8700. . . 

. 1. 

2. 

3. 

4. 

Is this patient under your care 

DYes 

Are you recommending medical marijuana for his patient due to a oiagnosis of Acquired 

Immunodeficiency Syndrome (AIDS) \ 

DYes 

. i 

a. If the answer to question 2 is "Yes", does he~she have anorexia DYes 

b. If the answer to question 2a is ·Yes", does h~/she h~ve weight loss DYes 

. ... \ '. 

Are you recommending medical marijuana for th(s patient due to nausea lnd vomiting 


a. If the answer'to question 3 is ·Yes·, has t.he patient failed to respond to conventional 


DYes 

DYes 

b: ~h~.answer to question 3a is "Yes·, please describe what those treatments were (medication, dose, 

u Ion): . I I· I I .. . 

..-.. __Ii. . , ... . 

.~ 16~·O,qtle~m~ J~K 

w . 

a. 

."an,we",,; to 'em, 2 & 3 above, what ~ the ",a,on YO" a,e ",oommendlng me,Hdnal "'" of . 

Ie M)::::'lde e'ldei p"bli, h! 

.{l.~ 

.,.,.'- 

DNo 

DNo 

DNo 

DNo 

DNo 

ale ·l.cienJl"$Ift.!"£~( "1/J'tP 

ma,I)"ana fa, thl' pu,!,,,e fll. ~ . ~ . r.=~ __________ ---,. __ 

. 5. While· on community supervision ("parole") the D~partment of Correcticins only authorizes the 





the Department's Medical Director of any changes i.n your answers ab.ove 

0 Yes 

.0 Yes 

DNo 

ONo 

poe 14-053 (Rev. 7/31/08) , .Doe 380.200 

PDU-6655-3 000411

I 


License #: 


Prescriber',s Signature 

License type: 

Phone Number 

Date 



He~.Ith Services Division 


PO Box41123 

Olympia, WA 98504-2113 

To be filled out by DOC Physic,ian: 

•• 1 

atijuana by this patient 

PpY,Sician' i S 

'i: j 

'·a 

Instruc ions to DOC Physician: ,(: \ 

When form is complete: ' "~t··. 

1. Email your finding above t9 the Assistant secretarY for. Community ,,'orrections 

", . i .... 

2. File this form and the accompanying Release of Inrormation in Liberty as a Community Corrections Health Record. 

State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andlor federal regulatio!,)s (42 CFR Part 2; 45 CFR Part 164) prohibit 

disclosure of this infoITlJation without the specific written consent of the person to whom it pertains, or as otherwise 


DOC 14-05.3 (Rev. 7/31/08) DOC 380.200 

PDU-6655-3 000412

I' 

j 

•••••" ••••••••_~ •• M •• 

... • ...........•. _. _•.• " ,_ ...._.. _ .w._ ••••... _........•...- OFFENDER 1.0. DATA: 




OF HIEAl TH INFORMATiON 

_____ , hereby authorize the use or disclosure of my health information 

The following individual or organization is authorized to make the disclosure: 

NAME: ___ ----~~----------------------------- 

ADDRESS: _______________ ~----------------____ _ 

The type and date(s) of information to be used or disClosed is as follows: 

y 

Purpose for disclosure: ,% 

i. u~d~~~tand;)haJth~ ii'ifoti]ladn In my health r~9.~r;J~rtJ.~y· if1,CIU~e information relating to sexually transmitted 

!nfec\io1.~, Acqureq/mR,1t:l2;oQ.:i.. . r!!;iy. ... ~¥.q~.rom· : "Iq~), ~r HLJJl1i;ln. Jmmunode~ciency Virus (HIV). It may also 

Include mformatlon about 5eha lor mental servl(~es andtreatmentfor·alcohol and drug abuse. 

-,- / . } :. . '::- '.~ "~t!f" ~~~ .; \. ...; ..... v . . 

This information may be djsclose~ to·an,g u~ed f;l 

.{glio~~g individual or organization: 

NAME:' -. .~ 

ADDRESS': 

-------~--~~~;~.~--------------~ 

i 'understand that I have a right to revoke this auth'orization at any time. I understand' that if I revoke this. 



response to this authorization. Unless otherwise revoked, this authoriza'tion'wiII expire on the following date, event, 

or condition: 

(if l

Living &: WeUness Centerss P.S. 

3716 Pacific Avenue, Suite E 


Phone: (253) 473-2663 

Fax: (253) 473-0545 

DOCUMENTATION of MEDiCAL AUTHORIZAT!ON to POSSESS MARIJUANA 

for MEDiCAL PURPOSES in THE STATE of WASHiNGTON 

The - ... \1 ••••• Washington State Medical Association. 

i_ - ••••• - •• - ...... 

. Patient Na 

Drivers LIcense Number: AlIa ...- VA tQJ.rrcl " 

Date of Birth 

"Sta~e: Ur!Y 

Washington Address Verified 

vYes_" _" No 

I, Scott L Havsy, DO, am an osteopathic physician licensed in ~he State of Washington .. I am treating 

the above-named patient for a terminal illness or a debilitating condition as defined in RCW 

69.51A010. (have advised the above-named patient about the potential risks and benefits of the 

medical use of marijuana. I have assessed the above-named patient's medical history and medical 

condition. It is in my medical opinion that the potential efits of the medical use of marijuana would 

likely outweigh the. healt s for this patient. 

Signature of Physician: ~~~:::::::Q~~~~c::;"'±-I---=-_ 

Today's Date: DeGew1:PY ;1, 01\ il r 

. / - 

. Risks and .benefits of medical marijuana: . 

Expiration Date: &ce uJv I (, d D.il 9' 

- ~ -~. 

Under Washington State Law, the use of medical marijuana is now permissible for some patients with· 

." terminal or debilitating illnesses. The law regulating this (RCW 69.51 A) allows physicians to advise 

patients about the risks and benefits regarding the medical use of marijuana. . 

The medical and scientific evidence according to the use of medical mariju.ana remains' controversial 

irfthe medi,cal community. " Not all healthcare providers believe that medical marijuana is safe or 

-----.::.effe-ctive-arrd-s-ome-prc:wid-ersfeennarins a dangerous drug. 

According to the Washington State Law the benefits of medical marijuana may include treating 

nausea and vomiting from chemotherapy; AIDS wasting syndrome; severe muscle spasms for 

multiple sclerosis or other sp"asticity disorders; glaucoma; and some types of intr,*ctable pain 

unrelieved by standard medical treatments and medications . 

. Some of the risks of medical marijuana may include possible long-term effects of the brain in the 

areas of memory, coordination, cognition; impairment of the ability to drive or operate heavy 

machinery; respiratory damage; possi.ble lung cancer; and physical or psycholoQicaldepen~ence. 

PDU-6655-3000414

I 

I 

Scott L. Havsy, DO, DAA.l.DM 


American Academy a/Pain ]v[anagement 

www.managedpain.com 

drhavsvi1ilcomcasrnet 

. ATTENTION LAW ENFORCE~1ENT 

I am a legal medical marijuana patient, as defmed by the Washington Medical 

Marijuana Act, RCW 69S1A. A copy of that document is attached to this letter. 

I have also attached a copy of my physician's recommendation as required by 

RCW 69.51A. 

My physician is Dr. Scott L. Havsy, DO, DAAPM and bls phone number is 253- 

473-2663. I have also attached a copy of my Washington State drivers' 

LicenselID. . 

I am in possession ofless than my necessary "60 day supply" as defined by RCW 

69.51A. I will not ansWer any questions relating to my status as a qualified 

patient, my medical condition, my dosage requirements or the number of plants 

that I need to meet my "60 day supply" or any other questions regarding my 

medical condition or medication. ,Ibis information is con.fidential and is strictly 

protected under the federal HIP AA law that protects the' con.fidentiality of my 

medical information. Requesting this information, without a subpoena, violates 

my right against self-incrimination. ' 

Furthermore, I will not speak witb:you unless I am accompanied by. my attorney. 

Any further attempt to speak with me without the presence of my attorney will be 

considered coercion. I do not, and will not, agree to a search of my home, person, 

property; or vehicle under any circumstances, without a search, walTant. 

This letter, the copy of my physician's certificate of authorization, a copy o(my 

Washington State identification, and a copy ofRCW 69.51A are being provided 

for your records and incident report: I encourage review of this documentation 

before taking action. 

__ DateJJ~brLD~ 

PDU-6655-3 000415

FEB-18-2009 14:56 From: 

To: 360 586 0252 

.' 


1813 130 th Ave N.E. #210 


Phone: 425-869-6186 or 1·800·723·0188 

Fax: 425.869·6378 

wwwtthc.-(gundntiou,Qti or· :wwwJ!!!mn.org 

Documentation of Medical Authorization to Possess Marijuana for Me~lcal 

Purposes in Washington State 

. . ~ 

The telCt ofthis·f'oim was recommended by the Washington State Medical Assooiation. 

Pa.tient 

ba:te ofB 

1, Thomas Orvald, am a physician licensed in the State of Washington. 1 am treating 

the above named patientfor atenninal illness or a debilitating condition as defined in 

RCW 69.S1A.Ofo. I he,ve advised the above named patient about the potential risks 

and benefits oftlre medica! use ofmatijuana.. r haveassclised the above.named 

patient's medical history a.nd medical condition. It is my medical opinion that the 

pot~ntlal berlcfits of the medical use of marijuana would likely ol.ltw=igh the health 

ri.sks for troll patient. 

t,;jgn~t'l.lre ofPhysiciati, 

:::r:~ OteU"~~tG £.A.t'b 

Thomas . Orvald,M,D. WA#MD00016180 

Today's datel$f ! a 2lJD8 Expiration date: . tsIP II 2009 . 

Ris~ and benefHs of medical marijuana: 

·Vndel' Wash,ington state law, the use of medical marijuana is now permissible for some 

patients with temlinal or d=bilitating illnesses. The laws regulating this CRew 69,SlA) 

allows physician's to adVise patients about the risks a.nd benefits of the medical use of 

marijuana.. 

' 

The i'fjodic;al andscientitic evidence supporting the USe of medical marijuana remains 

oontroversial ill the medical community. Not all health care providers believe tha.t 

medica.l marijuan.a is sa.fe or effective and some providers feel tha.t it is a dangerous dt1Jg. 

Acco,-ding to the Washington state Ia.w the benefits of medical marijuana may inch-ide 

treating nausea and vomiting fron' chemothera.py; AIDS wasting syndrome;. severe . 

muscle spa.sms froIn multiple...soJ~tosls-or-other.:.Spasticity-disor-derst-glaucomat-and-some---·--- 

types ofintractable pain, 

Some Qfthe risks of medical marijuana may include possible lo~g-term effer:ts of the 

brain in the areas of memo!)" coordina.tion and cognition; impairment of the ability to 

drive or operate heavy machinery; respiratory damage; possible tuns cancer; physical OT' 

psychological dependence - 

PDU-6655-3 000416

FEB-18-2009 14:56 From: 

To:360 586 0252 

~~c_~_: ____________________ ~ 

2. AM YQlJ ~bln9 mec!~ mlr~utIl'III ~ hf. pltlent Clut to • dl'"noIIla of AallJlred 

Iml'!Ml~aflclel'1rJY s~~me (AlI)!) . 

o. If IhIiJ Qn5\Wt tc ~u .. Uon 2ft 'V.,,", dCCII holt tie hili!! anorexia, 

Q. If the anuwor tL1 question 2a 10 'Vall', ~G he/llh. havo w.I;ht lollS' 

3. Ar~ yOu l:lrellcrlbln£l m.dlcal mMQu.n.1cr thl.'pltltInl .:Iut It! n.UM •• nd vomllll'lS ... oo~tcd t:l V~ , 

willi ~nO'tr ehemothe"lIY'i , ' 

~. If the Brli\\llr to qunl10ft a I, "Yeo', Mllh. paUe"t talllO 1(1 re.pond ~ IIQnv,"tlonlil 1""'1 V .. 

anllemitlOlfelitTIanti' ...., 

b, If ttle en~WM 10 qu;;UlIn Sa Ii "V1II5', plOU. d .. crlbo whit Iha,. traatm;nlV Wire (murJl~"Uon, G~II, 

~~ , ' 

G. Wttll II t~@ planned ~l1dule or ohtmoltlerapYP 

PDU-6655-3 000417

M •••• M •• __ • ___ • __ ._·· __ •• ____ • .. •• 

FEB-iB-2009 14:56 From: 

To:360 586 0252 

Praacrlbai': pie ... return thl. fQnn and the petltnt'. RalalH D'lnfOI'Matlol'l to: 

MocHClll OlrlO'lo1' 

I 

T hnve reviewed this vari:fiolltion fQm\~d find that usc ofmadIOlil1'nal'ijlltinaby~r, pntlCltt 

leI'IIlt:ItOll.,IOlo QItJ1l)t . 

cwlstant wlrh OOC Patill)'. .' '.' . 

hl.'NtlUtlttl 1.0 DOC PhVllcf.llR: 

Whtln fllfl'l'l I, QCf'npltll: . 

1, Elman your tlndlng ,I:IOVD III Ihll Anlltlnt Secrtlla~ fQr Oommun1tv C:ClI1'~Qnll 

2, Filtlhle torm and thl! aCC»1!I1JInylng ftelem or InfOtrriellon In 1.1_ n I CQmmunlty OcmIotIcna He~11h R~, 

PDU-6655-3000418

Dec, 12, 2008 4:01PM C B R Me die a 1 Inc, No, 2676 P, 1 

3'115 r.:. Mis!:iinn AVG 

Spokane, WA 992.02 

.T~l.Q)QniCLL1Jt5ie~Rloo~. from: rYIf:Jl~~~ rne._' .< 

.. f'

STAT!: OF WASHING"ON 

DEPART1\lIENT OF COAASCTlONS 

AUTHORIZATION FOR DISCL.OSURE 


OI'FeI'lCER LD. DATA: 


or organization is authorized 1:0 make the discfosure: 

NAM.E: 

ADDRESS: 

r tl f . ./~ti .. r/· (. ..

Dec. 12. 2008 4:.02PM CBR Medical Inc. 

No. 2676 P. 3 

Orf'ENOER I.Ll. c.c.TA: 

SiATE OFWASHING10~1 

DEPARTlVfENT OF CORRe:C110NS 

Me( 1einal Use of Marijuana Verific~tion 

To b ~ filled put by Prescriber: . . 

Deal Prescriber, . . 

By s ate statute the Washington State Department of Corrections is charged with the responsibility to supervise some 

off!!t ders after they have been convicted of a felony. The above named patient is currently under supervision by the 

Dep, ,rtrnent SupeNision is designed to help the offender avoid those environments Of sItuations that read to their criminal 

beh. vior. Often illicit drug use is a contributing factor in ar.J individual's criminality. Accordingly irs usual that the courl or 

the r 'epartment of Corrections will impose a condition of supervision that the (,ffender not use, or possess illicit drugs; 

it)c!u jing marijuana. nls offender has .claimed that they have a oondition for which the medidn:al use of marijuana has 

beer recommended. The below verification is to determine the legitimacy of their claim. Thank you.in advanr:e for your 

. assu· tance. If you have quastion~ please feel free to personally contact the Medical Director of the Department -(360) 

725- 3700. 

1. 

"1 

Is this patient under your care· \2(" , 

2. 

3. 

Are you recommending medical marijuana fo@atient due to a diagnosIs of Acquired 

Immunodeficiency Syndrome (AlPS) 

a. If the answer U; question 2 is ·Yes·, does he/she have anorexia (II' 

/0' . 

b. If the answer to question 2a Is "Yes", does he/she have weight loss !VII+- 

o Yes 

EtrC'-'aNo 

/31'es"'--r:I No / 

./ 

cz(NO 

Are you recommending medical marijuana for this patient due to nausea and vomltlng 

Dyes 

associated with cam:er chemotherapY 

a. If the answer to question 3 is "Yas", has the patient failed to respond to conventionalrllr- g.~ IT'No 

antiemetic treatments . . . 

b. If the answerto question 3a is "Yes", P1aa7 describe what those ~atmenls were (I}1edication, dose, 

~uration): . rJ A '. . 

c. What is the planned schedule of ChemOtherapYf/ I 

trr 

4. 

a. 

If yo.~ answered "No' to items 2 & 3 above, what is U1S reason you are rec:ornmendin~ medicinal use of '\ :\ 

manjuana' \ _., '\,....\n-,-T-v..'o\e ~~- ·Jr-.[i! .. .\iV'-"e/} \1 )~u,,~\ .~..t.tlI..n.a; 

v'rJ Or-,Zo.. ..- . \ . ,'. . 

-X\--V~f t I :'(.e. •. ,.. 4 '1'" C.r4~~ . . 

please provide evidence published in a peer-reviewed scientific pUblication ~o' support the medicil)aluse of . 

marijuana for this purpose '" ~_ ~~t. 6- 

S·u.- - 

5. 

6. 

While on ·communlty supervision ("parole") the Departrnent of Corrections o~(y aut!1ariz~s the 

use of the oral synthetic formUlation of marijuana. If the Department aut~onzes thiS patient's 

use of !11edical marijuana, will you' be prescribing only the oral synthetic formulation 

The patient's accompanying Release of Information autho~e~ you to provide the .' 

Departmsntwith current and future Information related to thiS Issue. Do you agree to notifY 

the Departmenfs Medical Director of any Chl;lnges in your answers above 

. 0 Yes 

DYes 

DOt 14-053 (Rev. 7[31/03) 

DOC:;80.2(){l 

PDU-6655-3 000421

Dec. 12. 200 8 4 : 03 PM C B R Md i cal Inc. 

,/1 No. 2676 .P. 4 

~ .. ;' .. 

"I ;" ".c·~'· ...... 

/ ( / 

jj:\i+r\tj}~ -:S.iLh..c.J5.0,A ._..- 

/ 

~fI!S!!"JUm" ame (Prtnt) 

~ r"\'r=S\~.4'~:t t.\ .. ~ 

../ ~==-- ~'~V:y-. 

wre 

!':g te 

Licel sa #: __ ~ (~[) (;:J ,~. 0; (; c{ ['. __..:;,A.!

Dec. 12. 2008 4:03PM. CBR Medical Inc. 

...... - -_._--_ .. ---'--------,----- 

No.2676· 

P.5. 

II. 

#:_ 

Date: 1217/08 

To: the A,t!silltflnl SGgt~iJyfor CommUl1i~y C()1Tecl~QI1t1 

lo'rom: Antoine D; Johnson, MD 

Topic: Medical Marijuana Denial fOl' DOC 

Discussion: 

Hclio and good day. S('lTIltllime of November, 2008, the DeparlTUenl or 

, Services gavc notice of his/her decision not to allow 

tJCmedically re~()mmendcd marijuana. . 

.As both the Medical pircctor of CBR Medical Tnc. uml;Jn advocate tor my patient' 

Mr._r respeclfu~ the rcasones) proffered by the Director 0 r Medical . 

Services for denying Mr._'l1cdically recommended marijuana 

, lJPOJl rcview of the Mr._medical chart, it appears that procedural 

requiTemenL'I as expressed in the Departmen[ or C()rrec~i()ns POUey (' see p. 5;1I'lV; 

DOC 380.200) have been followed. further, l:>tatllt()ry requlremenL'l as expresr.cd by 

RCW 69.51 A have also been fol1owcd. 

, Carc.ful review ofMr_C)C 14·053 form I~vcals it was revised 5/16t~ 

r am aware of a subsequent revision lo said Ihrrn. Attached is a completed DOs;.Jzf.:Q'S3 

form (7/3l/08~vicw. Also aU.ached ill a Pf;leT reviewed scicnti l'ic,PtlDlieatlon 

respe\.'ting Mr __ RCW 69.51A qualifying medical mne~S7Tespe 

with medicallTI

Dec. 12. 2008 4:04PM I CBR Medical Inc. , ... 

t;:ar1ll8tl[SDCWS.~:()I1i: \ ;Tohr: ~I un i""S'( J.'cr IVI~('aid. 

Rob Killian, the primary ~"pOIl.Sur ufInitiativc 692, testified 011 behalf ofthc petition .. Many Crohn's paLitlnt.s 

have long espoused. the use ofmarijuarta to case more Revere sympt(jm~, he said. . 

"By adding this il·lness to the list, we arc further safeguarding ecution for using il medicine that works," he said. . 

Under tile "tW, the commission mURt cOl)sider petitions :;ubmiited by patients' or physicians Lo add termInal Or 

debHitating condjtion~' lo those covered hy the act. 

King said the next petition to he considered will be fur hcpatitlsC, a virus that can calise anurexia, abd~1minal 

di~comf[)rt, nausell lind vomi~lng. .... 

Carol M. Ostrom's phone message number is 206·464·Z249. 

f fer e-mLlil address is cosu·om@Reattletimes.eom 

Posted: Tuesday, November 9, 1999 

Copyright «,) 1999 The Seattle 'rimes Company 

Reluted Article & Web Site: 

Washington Citi7.em; For Medical Rights 

httn . {1C' .. nn

NOY.25. 2008 3: 06PM CBRMedicallnc. No.2414 P. 2 

11125/08 

is_ 

Attn: Monica DeStcpbano 

Re: 

DOC 

Hlatcs it 

Sa f e ( L Q 9 a I A P pro a c h toM G dIe a I Mar i i u.a n a 

Dear Moruca DeRlephano, 

We are anticipating submitting appeal on or soon after December 7 th when patient. will see 1)1'. Johnson 

'to work on appeals process and additillnal medical documentation l~lr lhat appeal. . • 

Any attempt to force Mr._into a drug treatment program for a drug thaf has been recommended 

by his physician will be met with swift legal action against the DOC. . 

If you ha:ve any questions or ,concerns plea'3l;l call me immediately on my cell pho11e at 509-570-2886. 

. . . . 

/ofo 

Sincerely, . 

.. ,4.~ ~ .. 

. 7(;2t~'~ ,~ ~.~ ~'1 17 . 

Melissa Leggee . . 

C,BR Medical, life. 

3115 E Mission Ave 

Spokane) WA 

8C!1ll1c Phone 206-774-6493 FaJ> 206-41S-6659 SpokaIl.e Phone 509·242-8624 [lax 509-340-2710 

Tri-Ci1ies Phone 509-416·2267 fi'tixS09-340-2710 Vancouver Phone 360-635-6164 Fax20G-41 R·MS!} 

eRR Medical, [nco - 311511 Mission Aw, Spukanc, Wa.99202 

PDU-6655-3 000425

. Nov. 2~. 2008 3: 05PM CBR Medical Inc. No.2414 P. 1 

Fax .. 

caR Medical I~ 



I:l Please Reply 

0 Please Recycle 

-Comments: 

. . CBR Medical, Inc. - 3115 E. Mission Ave, Spokane, Wa 99202 

Seattle Phone 206-774-6493 Fax 2.06-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 

Tri-Cities Phone 509416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 . 


entity to wl~om it is addressed, and may contain information that 'is privileged, or confidential and 

exempt from' disclosure under applicable law. You are hereby notified that any dissemil1ation, 

distribution, or duplication of this communication by someone other than the intended addressee or its .' 


AI.llnformation is Protected Under U.S. Federal Law 

PDU-6655-3000426

Distefano. MonicaJ. (DOC) 

From: 

Sent: 

To: 

Cc: 

Subject: 


Thursday, November 13, 200810:19 AM 

Brucick, Jack M. (DOC); Curran, Michael L (DOC) 

'Dan~__ . 

FW~edical Marijuana Authorization Request 

FYI 






Tumwater, INA 98501 MS: 41126 

(360) 725-8796 


From: 

Sent: 

To: 

Subject: 


Wednesday, November 12, 2008 8:56 PM 

Marijuana Authorization Request 

I have reviewed the request from this patient/offender for authqrization for use of medical marijuana and have found that it 

cannot be authorized in accord with DOC policy. . .' 





POB 411'23 


360~ 725-8 700 

1, 

PDU-6655-3 000427

"NOV-12-2008 WED 01~45 PM SPOKANE'NBS UNIT FAX No. 50'9-482-3853 p. OQ4 

~ I,IV

'NOV-12-2008 WED 01: 45 PM 

08/~4/2ooa 2Q:45 FAX 509340.2710 

, SPOMNE NBS UN I T 

FAX No. 509-482-385'3 p. 005 

laI OO$/ooa 

Prascrlber: please return this for~ and the patient's Release of Information to: 


,Heruth SerVices Division 

Washington State Department ofCo1l'ectioos 

~O Box 41123 

Olympia, WA 98504-2113 

To be fllled out by DOC Phy~lcl~/1: 

1 have reviewed this verification raztfi and find that use of medical marijuana by this pattent 

, 

a 

(dI~cI< cna) lOis IMfs not ~/ ' 

con~tent ~th DOC ~Olicy., ' ' " ' 

.,SteVb\ HuiAAvv,.~l.~l> ,hJ~ 


pny5Iclan'~ Slgl'lllMe 

Inatrl,lr;tjonG to tlOC Physlg!an: 

, . 

When form Is oomplete: 

1. Email your finding above to the Assistant Slicratary for Community Correc~onB 

2. Fi!e this form and the accompanyIng Release of Information in Liberty as a Community Corrections Health Record. 

" . 

,slatdaw (ReW 70. 1}2: RCW 10.2

j " 'NO~:12-2008 WEO 01:44 Pi SPOKANE NBS UN[T. FAX No. 509-482-3853 p. 001 

I 

DEPARTMENT OF CORRECTIONS, 

. . 

OFFICE OF CORRECTIONAL OPERATIONS'. 

:NBS UNJT/NORTH NEVA~Woob COPS 

4705 N. ADDI$ON', SPOKANE .WA 99207 

.. FAX (509) 482-3853 : 

, . 

! 

FROM: 

TO: 

S+evp- 

" FAX: (3,,0) 

=:' .. 

~ Jack Brucick 

D . Lynda Douglas 

o Kira Bliss 

H~ 

(509) 482-385~ 

(509) .482-3856 

(509) 482-3857 

W=:f761 . PHONE: '(3 ,,~ . 7~S - g 761 

- 70&'1)' 

. TOTAL NO. OF PAGES INCLUD[NG COVER: 

~ '. 

/0 

o Per your re~uest 

Confidentiality, Notice 

.' , 

This facsimile tran~missian, a,nd any·document(s) accompanying it, may contain confidential information belongir:tg 

to the sender, and which may, in part or whole" be protected. by Title 18, United States Code, Section 3153(c)(1) 

. and, Pretrial Confidentiality Regulations. Thi~ information is'intend'ed solely for the use of the Indiviaual or entity 

named above, If you are. not the intended recipient, you are hereby notified that any disclosure, copying, , 

distribu!iolJ, or the taking of any action in reliance upon the contents of.this infonnation is prohibited. If you have 

received this transmission in error! contact our off/ye by phone ImmediatelY: to arrange for the return of the 

document(s) transmitted. Thank you for your fulf'cooperation {n thi~·matter. 

PDU:.6655-3 000430·

\ " 

'NOV-12-~008 WED 01:44 PM SPOKANE NBS UNIT FAX No, 509-482-3853 p. 002 

Otl)b51200B O~:3~ ~AX bO~~40~(10 IgJ VV IfVVD 

Sa h 

CBR 9v1edica[rnc. 

L II 9 a I.A p pro a c h toM e die a J Mar" u a "A. 

DATE; j'Llly 25, 2008 

TO: 

Scott Wright 

Phone: 509-568-3106 

FiIX: 509-568·3104 

Pages: 6 

RE:Patient __ 

Dear Mr. Wright; 

T understand from our patient, Mr_thatyou have some questi~ns regilrding our patient's use of 

medical marijuana. 1 believe:tbat Mr. ~Tovided you with a meclica! marijuana reeommcmdation that was 

signerl by Dr. Antoine Johnson on May :lrd, 2008. ' 

' 

This recommend4tion complie~ compl=ly with Washington Stale law (Rf:.W 6!S La) as legal authority for 

Mr_o posse5S 1't\lI1ij'Uana and have THe ttl his SY-stern. The law does not preclude him frem these rights UJ1der 

the state law unless he is actually incarcerated at the time. The right of doctors to write these recommendations is also 

protectlld under the 9 111 circuit Federal Court of Appeals ruling in Conaflt v, WaUar:. 

It is exc\usivl:ly up to the patient' £ physician, and not DOC officers, to make the decisions on what medication 

Ii patient should legally be aUowed to have in their system. For a. DOC officer to "recommend", let alone "order" ,an , 

. alternAtive medication. for B; patient, rather than me one recommended' by the pa.tient' s own physlelan, could easily be 

construed as a gross violation of the pbysician/client relatiQn~hip and even "prC)scribing without n license". Th.is wQuld 

violate sevc-ral state laws. ", 

We are aware that there is a policy circulating through the.DoC that is attempting to f9J:C:e paue.\lts to use 

Marinol (dronabinol) instead of medical marijuana. Please bea.ware that the Drug Enforcement Administraticm has 

threatened doctors with the lciss of their DBA licenses, and possible Federal Prosecution, if they recommend MminoJ 

for any conditions bestd~s wasting from AIDS and cancer patients undergoing chemotherapy. These are tilo only two 

, conditions for which the drUg was specifically approved. 

\\'hile r am prohibited by federal HIP AA laws from discussing Mr. medical condition with you, I 

can ten you that he has neither of these oonditions and would not be a candidate for a presoription for Marinol under the 

CUmlnt federal guidelines. 

Any ~mpt to force Mr._into II rlnlg treatment program for a drug that has ,been recommended by his 

physician will be met with swift legal action agaiJ')st the DOC. 

' 

ram on tlie roacra gr¢at ~a.rormTnme, M1'IJOelUippy to dlscussthe sffiJition W1ffi you If you wlsu.you 

can l"Oaoh me on my cell phone at 509·570·2886. 

;#~/k 

Melissa Leggee . 

CliniCl DirecIOt' 

Seattlo Phone: 206·774·6493 Fax 206-41 &·6659 Spokan.: Phone 509-24.2-B624 Fax. 509-340-2.710 

Tn-Cities Phone 50~-411i-2267 Fax: 509·340-2710 Vancouver Phone: 360·635-6464 Fax: 206-418-6659 

CBR Modical, Int;: .• 3 tIS E. Mission Ave. Spokane, Wa 99202 

PDU-6655-3000431

"NOV-12-200B wED 01:45 PM 

08/'~/lOD~ lu:44 ~AX bU~~qvlrlu 

SPOKANE NBS UNIT 

FAX No, 509-482-3853 p, 003 

~VVI/VV\J 

OFFE.'IC=." I,D, DATA: 

\ ' 

STATIO 0/= WASHINGTON 

CEPARTMENTOF COltRS0110NS 


OF HEALTH INFO~MATION 

I. ...... L~ ___________" 

hereby authorize the use or disolosure of my 'health information 

!IS desc(lbed belew, The following IndIvidual or organlzatlon Ie authQrized tQ m!!!ke the disclosure; 

, NAME:' 66 e.. MM; c;"'r 

ADDRESS: -;s \ 15 p.. A . ssi Q Q '8 J e 

~b¥.P't'U' IV ~ 9 q "2..0 ~ 

. 

The type and date(s)of informatlOIl to be used or disclosed is i*l follows: 

M.~ i c:-l. 

~tf~;;r~~,~o,~; ~J,~1;;;:4: 

PtJrposefor dl$oI06UI'e! V -€ V--;, C'y ; ~3 lMe J~~.( VU 4 C -'J ,.113 "" 4, eO OJ' row bdi:b~ rt 

I understand that the Information in my health reoord may include Information relating to sexually transmitted 

infections, AcquIred Immunodeficiency Syndrome (AIDS), or HUman Immunodeficiency Viruili (HIV). It may also 

Incll,lde information apout b~havlotal or'mental health services and treatmelltfor alcohol and drug abuse. 

This Information may be disclosed to ;and used ~y the following Individual or organization: . 

NAME: Scott Wright 

ADDRESS; 630 W. Shanno(J 

Spokilns, WA 

99205 

I understand that I have a right to revoke this authorlzetloo st any Ume. 1 understand that If I revoke this 

authorization I must do so In writing and present my written revocation to the Health Information Management 

Department. I understand that the revocation will not apply to Infornllii![on that has already been released in 

resllonse to this authoilzation. Unless oth9:1.ise/evoked. thi!! autiioriza:ion will expire on the followlog eate, eveot, 

,or condition: 8Q'1$!f"'7tbQwe"'~f rDF~'f left blank, aut"Ioriza!loil w!1I eXflire sIx (6) months from signIng). 

I understand that authorizing the disclosure of this health Information Is voluntery. ~ can refuse to sign this . 

authorization. I need not sign ,thls'form in Qrd~to assure treatment. II.mderstand that I may iMpect or copy the 

information to be usee' or disclosed, as providid in CFR 164.524 alld RCW 7Q.02. I understand Ih

'~OV-12-2008 WED 01:46 PM SPOKANE NBS UNIT 

.08/05/2008 03:39 FAX ~O~840lilU 

FAX No, 509-482-3853 

P, 009 

Iod:J V "-.ir ....... 

Documentation of Medical Authorization to Possess Ma(ijuana 


PATIENT NAM5.: ___ _ 

DATEOF6IRTH:~ 

I, Antoine Johnson , m a hysicien licensed in the State OfWil!~hinston • 

and I am treating the above patient tor $ rminal i ness or II debilitating condition as defined by 

ROW 69.S1A.010. 

I have advised the above named pati t about the potential risks and benefits of tile medical us~ 

of marijuana, I neve assessed the a ove flamed tieot's medical history ~!'Id medical oondition, 

It Is my medical opinionthet the pot ntial benefits f the medical use. of marijuana may outweigh 

the healtn risks for this patient.. 

Phyeioian N~me: ----'=.:...::.:;'=t'~=;.:o.=.;....-+-- Will License Number: MD00039046 

Physician Signature: Date: 05/0:3/~OOe 

T.his reeomm~ndation $xr-ire{,cn: 05/03/2009 

( 

Risks an.d benefits of m&dieal marUualla 

Under Wa$hington law, the !.Ise of med' al m rij4Ma is now permissib(e for some palien.ts 

with terminal or debilitating Illnesses. Th law r gulalil19 this (ReW 69.S1A) allows physicians 

to advise patients about 1he risks and be efits f the medicall.lse of marijuana, 

The medical and scientific evidence uppo ng the Use of medical marUl.lana remains 

.' controversial inlhe medlcal'community. Not al health care provider:; belle .... e that med.ioel 

marijuan:a is sJafe or effective and som prollid rs feel that it is a dangerous drug. 

According to the W&lshingto'n State I w the benetit5 of medical marijuana may include 

traflting nausea and vomiting from one othe Py, AIDS wasting symlrome, sev'ere m4E}c1e 

spasms from multiple sclerosis or other spas icity disordera,Qlaucoma, and some types of 

intra~ti\ble pilIln. 

Some of the riskS of medical marijuan ay include possible long-term effects of the brain in 

the areas of memory. ooordination and cognition; impairment of the aoility to drive or operate 

heavy machinery; reSpiratory damage;. possible lung CClncer; and physical or psychological 

d(Olpendence, 

Raaomm~ndliirir;Jn 

As thla patient's "60 day supply", as stipulated by RCW eS,S1A(2)(b), I recommend 24 ounces. 

of t;lrleQ, cl,mi:d marUuene and as many plants as the patient feels necessary to nlilintain 1his "60 

day supply", . 

PDU-6655-3 000433



P.O. Box'41100· Olympia, Washington 98504·1100 


Carson, WA 98610 

DearMr_ 

Your Medicinal Use of Ma!ijtiana request was received on January 8·, 2009. Upon review by the 

D~partment of Corrections' Health Servic~s physician; your request has been denied. 

You may appeal this decision by sending your written request within 15 business days of this letter; 

which"is qn or before February 16,2009. 'Please'send your request to the address below: 

. . Karen Daniels, Assistant Secretary 

. Community Corrections Division 


P.O. Box 41126 

Olympia, WA 98504-1126 

Your request must provide additional infOImation that was not incl:uded with your original request. 

Appeals that do not contain new information will be denied. You wil1.receive a response to your 

appeal request within 30 days ofr~ceip~. . 

. c ely,. . 

~ 

. Ii vutO 

I. are D8.J.-ue s, Assistant Secretary 

CommuIrity Correc;tions Division 

KD:md 

cc:. John Kopf, CommUnity Corrections Supervisor 

------'---~Don Swanson, Commuruty Correchons Officer 

Field File . 


Dr. Rod Krehbiel, :MD' 

LCDC in Hood River 

849 Pacific Ave. 

Hood River, OR 97031 

" Working Together for SAFE Commu.nities"· 


PDU-6655-3 000434


From: 

Sent: 

To: 

. Subject: 


Friday, January 16, 2009 8:42 AM 

~); Daniels, Karen R. (DOC) 

~MRequest 

Mr._equest for aufhorization for medical r'narij~ana use does not meet medical necessity criteria. 




Department of Corrections· 

POB41123 


360-725-8700 

1 

PDU-6655-3 000435

·I~I La Crmica tid Carifio 

~':./ . Family Health Care Center, InC. 

LCDC In Hood River 

849 Pacific Avenue 

Hood River, OR 97031 

541-386·6380 

. Fax 541-386-1078 

LCDC In The Dalles 

425 East 7" Avenue 

The Dalies, OR 97058 

541-296-4610 

Fax 541-296-5813 

Patient name: 

To Whom it May C~nc~r: 

his leg on a constant basis. 

been under the care of this clinic for several years_ He has used medical marijuana for his chronic pain with excellent 

from severe p~in stemming from a complicated femUr fracture and ostemyelitis in 1981. He suffers severe burning pain in 

I would like to request that~e allowed to continue his current use of the medication. I do not feel that switching him to the oral form 

would be as effective for him. 

Thanks for your ,consideration, 

Rod Krehbiel M.D. 

}' 

LCDC provides best-quality medical and dental care to people afthefour counties 01 the Mid-Columbi~ Gorge, especially peoRle 

who might 0U:erwise be "under-served" due to economic or cultural issues, in a manner that honors their economic and cultural neel;fs, 

Le Cllnlca del-Carino is an Equal Opportunity Employer and Health Care Provider. 

PDU-6655-3000436

OCT/22lZ00S/WED 02:27 PM 

DOG WEST V,~I{ 

f) .. 

FAX No. 36057660.09 ,r' 0, 

I \ 

t. 

P. 003 

< ......,,"..,.~ 

.1Jll& DEPARTMENT 

f ~ 'J 'STATE OF WASHINGTON 

OF CORRECTIONS 

Medicinal Use .of Marijuana Verification 

OFFeNO~R 1.0. OATA; 



offenders after they h~ve been convicted of a felony. The above named patient Is currently under supervision by the 

Department. Supervision is designed to help the offender avoid those environments or situations that lead to their crirl)lnal , 

behavior. Often Hllcit dn-!g use Is a contributing factor in an individual's criminality .. Accordingly It's usual that the court or 

tha Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, . 

inclu'ding marijuana. This offender has claimed ih

UCT/l~/ZUUH/WKU Ul:l1 PM Due WE:;)']' VAN. 

() 

HX No, :JtiU~'/titiUU~ 

. '_ ..... , 

p, UU4 

Prescriber: please r.eturn this form and the patient's 'Release of Information to: 



Washington Sta.te Department ofCoIl'ecnOns 

PO Box 41123 

Olympia, WA 98504-2113 



Physldan's Signature 

Date 


When form Is complete: 

1. ' Emaii your finding above to the Assistant Se'cretary for Community Corrections . 

2.· File this form and the accompanying Release of Information In LIberty as a CommunIty Corrections Health Record. 

Srare law (ReW-70.02: !

$TATE OF WASHINGTON 


P.O. Box 41100' Olympia, Washington 9850~-1 100 

February 17, 2009 

Lacey, W A 98503 

Dear MS._ 

, 

I received your request from. CBR Medical; Inc., on January 5,2009, to appeal the denial 

of your initial Medicinal Use: of Marijuana Verification. . 

In the interest of public safety and protection. of the community at large, I find your 

request for ~edicinal Use of Marijuana, while under the supervision of the Department _ 

~f Corrections, is denied. 



Sincerely, 

./J ......-----.t"' 

'. ). 



KD:md 

. cc; . Sasha Brooks, Community Corrections Officer 

Kurtis Smith, Co~Corrections Supervisor 

Field File - DOC _ . . 



__________.l..C.J: 

BuR>-Me.d1c;ca:uI....:...-_______________ ------:------- 





PDU-6655-3 000439

(;tlKlVledlcalln·c, 

(. 

I~o, LtlL/ . y, II jO 

I Fax 

caR Medical, Inc 

3115 E. M~ion Ave 


.' 

o .. "'01' R=';-w' ~..... 0 Pl- _$ e C ol11ll'len to' 

Pleas.a Reply Cl Please Recycle 

.Commentsl 

, CBR Medical, Inc.· 3116 E. tIilisslon Ave. Spokane, Wa 99202 

Seattle Phone 2rJ-774..e493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2.71 0 

Trt"CiUes Phone 509416-2267 Fax 509-340-2710 Vancouver Phone 361}·635·6464 FaX ;lQ6-418·6659 

CONRDENTIAUW NOTICE: T\'ris communication is intended for the sole use of the individual and 

entity to whom it is ",ddressed, 8[1d' may cantsm infOrmation that is privileged. or flOnfidential and 

exempt from disclosure under

Dec, 23, 200B ~: 31PM CBK Med i ca I Inc, 

No,2B21 p, 2/36 

STATE OF' WASHINGTON 

OEPARTilliENT OF CORREctioNS 


TH INFORMATION 

OI'r-CNOER 1.0. OI\TI\: 


organizatiori is authorized to make the disclosure: 

"'M"" C 'b h J. f. i , . t1 ''-j"'' 

''''' 0:;. "t\ "'_. J~tLC-l " C .. ··· ... ·, .....!-,·h. C 

ADDRESS: "'6 I \ ":J ·t::;,.--'--o,-

Dec.23. 2008 ,:31PM GSg Medical Inc. No. 2821 P. 3/36 

..;I' .... ' .. ''''~~ 

, 

( . l' STATEOf'WASHINGTON 

DSPARTMENT Of COr:!REcnONS 

. Medicinal Use of Marijuana Verification 

OIH:NnFR 1.0. DATA: 

Dear prescriber, 

By stete statute the Washington State Department of Corrections is charged With the responsibility to supervise some 

offenders after they have been convicted .of a felony. 'The above named pati~nt ilii. currently under supervision by the 

Pepartment. Supervision is designed to help the offender avoid those environments or situations ·that lead to their criminal 

behavior. Often illicit drug use is a contributing factor. in an individual's criminality. Accordingly it's U5uatthat the court or 

the Department of Corrections will impose a condition of supervision that the c,ffender not use, or possess illicit drugs, 

including marijuana. This offender has claimed that they have a condition Tor which the medicinal use of manjuana has . 

been recommended, the belOW verification is·to determine the legitimacy of their claim. Thank you in advance for your· 

assistance~ If you have questions please teel free to personally contact the Medical Director of the Department at (360) 

725-8700. . . . 

1. Is this patient under your care ~ D No 

2. Are y~u recommending medical marijuana for his patient due to a diagnosis of Acquired 


a, If the answer to question 2 is ·Yes·, does he/she have anorexia 

b. If the answer to que~tion 2a is "Yes',~oes he/stie have weightloss 

3. Are you re~mmending medical marijuana for this patient due to nausea and vomiting 

associated with cancer chemothe~py . . " 


antiemetic treatments· ... /11+- 

DYes 

. g-~ 

. rv(r'7 Ol->,''''''',,'''s -4.d-No 

Nff* D ¥es rj-No 

DYes 

QVes 

h. If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose, 

. duration): . 

. [rNc:· 

fiNo 

4. 

c. Whatis th·e planned schedule O{Chemoth~h . 

If you answered "No" to items 2 & 3 above, wh~t is the reason you are recommending piedidnal use of 

marIJuana. . e.:.. (" "'.. I>.,.,-'\...~" '~ . 

" . . J \, 

a. Please provide evidence pUblished in a peer-reviewed SCientific publication to support the medicinal. use of 

marijuaWil for this purpose' S· \-\--t ~ \...~ .1'\' . . 

____ -:-___ ---:.. __________ ~ ~ r-., ~~. .' {~ 

'~------~--------------~---- 

5. 

6. 

While on community supervision ("parole") tile Department of Corrections o~IY aut~oriz7s the 

use of the oral synthetic formulation of marIjuana. If the Department authOrizes thiS patlenrs 

use of rnedir,al marijuana, will you be prescribing only the oral synthetic formulation 

The patient's accompanying Release of Information authoriZes you to provide the . 

Departn'ient with current and future inform;ation related to this [ssue. Do ~ou agree to notify 

the Department's Medical Director of any changes in your ansW(3rs above· 

O· Yes 

0 Yes 

lJOC 14-053 (Rev. 7J31/0S) 

J:lOC·3BO.200 

."1; . 

PDU-6655-3 000442

Dec. 23. 2008 5: 32PM C B R Me d i c a 1 Inc. 

,-:7'1" 

0" ,., 

No. 2827 P. 4/36 




PO BoX'41123 

Olympia, vyA 9850~2113 

---...... ---.~-'---... --...... -'- 


I have reviewed this Verification form and nnd that use of medical mariju~lOa by this patient 

(check'one) lOis ' [j is not ", 


' 

Instructions to POC Physician: 

'--_.......- .-'-:-. 

When form is complete; 


2. File this form and the accompanying Rel~ase of Information in Uberty as a Community Corrections Health Record. 

Stare IiiIN' (RCW 7(l.02j RCW 10.24,1 os; RCW 71,05.390) andforfet\l!ral regul",tlons (42 em Part 2; 45 CFR p"rt 154) prohibit 

disclosure of this information without the specific wriLtcn consen~ of the p91'SOn tn whom it pertains, of as oth .. rwlse 

permitted by !ilW. 

DOC 14-.1)53 (Rev. 7/31/08) 

000'380,200' 

PDU-6655-3 000443

Dec, 23, 2008 5: 32PM CBR Med i ca 1 -Inc, No,2827 p, 5/36 

_ Documentation of Medical Authorization to Possess Marijuana 

'for Medical Purposes in Washingt~m State 

PATIENT NAME: ~_----' 

DATEOFBIRTH:~ 

I, - Antoine Johnson ' ,am a physician licensed in the State of Washington 

and 1 am treating the above patient for a terminal mness or a debilitating condition as defined by 

RCW 69.51A.01 D. - 


of marijuana. I have assessed the above named p.1iltient's medical history and medical condition. 

It is my medical opinion that the potential benef~f the medical Lise of marijuana may outweigh 

:the health risks for this patient. _ /,1'/ _ . 

Physician Name:. Dr. Antoine Joh!')ion " 

WA License Number: - MD00039048 

,/' 

./ 

Physician Signature: __-..,,;...l_......;~~___ ~ Date: _ ........_121_1_4_/2-'-0-'-08 ____ 

I . I 

This recommendation expires on: 121[4/2009 _ 

Risks and-benefits of medical marijuani . . - - _.' - '- 

Under Washington law. the use of d,edical marijuana is now permissible for some patients 

with terminal or debilitating iIInesseS£he law regulating this (RCW 69.51A) allows physicians 

to advise patients about the risks an. benefits of the- medical use of marijuana. 

The medh::al and scientific evicle ' e supporting the use of mediCal marijuana remains 

controversial in the medic6l1 commu ity. Not all health care providers believe that medical 

marijuana is safe or effective lind some providers.feel that it is a dangerous drug_ 


treating nausea and vomiting from chemotherapy, AIDS wasting syndrome, severe mU$cle 

spasms froll! multiple sclerosis or other spasticity disorders, glaucoma, and some tYpes of 

intractable pain_ - - 

Some of the risles of medical marijuana may include possible long-term effects of the brain in 

the_ areas of memo!)" coordination and cognition; impairment of the ability to drive or operata 

heavy machinery; respiratory damage; possible lung cancer; and phySical or psychological 

dependence. 


. As this patient's "60 Pay Supply",a.s stipulated by RCW 69.51A.040 (3)(b) and 

WAC 246·75.010, this Qualifying Patient can reasonably expect to have in their Pose$sion and 

-------INeed-a-total-ef-ne-mere-thaA-24-GuAGes-ef.!!l-Jseable-Mar-ijuafla!LaF\d-R0-FfI(')ra~thaA-1-§-F!laAts,s.,----~~-- 

CBR Medical~ (nc . . 



Spokane: 509-242·8624 Fax:509-340-2710 

Seattle: 205-774-5493 Fax: 205-418·6659 


CALL 509·570·2886 OR 509·570·6943 

PDU-6655-3 000444


From: 

Sent: 

To: 

Subject: 

Brooks, Sasha M. (DOC) 

Monday, December 08,20089:21 AM 


MM Request 

Thank you for the update. I 

Sf'sha 

.... '.1 

Br~onlrC' v,,,,,''' . 

Community Corrections Officer 2 


Olympia Main Field Office (364) 

(360) 493-9471 office 

(360) !1.Q7-007~ fax, 

From: 

Sent: 

'To: , 

Subject: 

FYI- 


December 08,20089:18 AM 

i 

il.iliil~MKurti~ R: (DOC) 

Request 

, This offender's request has been denied. 

Monica Distefano' 


Karen Daniels, Assistant" Secretary 


7345 Lindersan Way SVV 


(360) 725-8796 

mjdistefana@doc1.wCj.gov 

From: . 

Sent: 

To: 

ee: 

Subject: 


Wednesday, December 03, 2008 5:23 PM 

Daniels, Karen R. 

I found this patient's request for medical marijuana not to be consistent with DOC Policy. 





1 

PDU-6655-3000445

CO (') -K~ . C c..l)' ,_ .,..,. 

ADDRESS; ~tf c::,c: kt 20 «";)~): '\]1:-::' ,'\ ~ p=r. t:f-~ r r 0 ,c.:t I 001\,,:) 

I understand that I have a right to revo~e this authOrization at any time. I understand that if I revoke this 

authorization I must do so in writing ~Ild present my written revocation to the Health Information Management 

Department I understand Inat the revoca~on will not apply to infolTl'lation that has already been released in 

response to this au orizati9n. Unless otherwise revoked, this authorization will expire on the following date, event, . 

or condition: .' ,Q Ld

t' 

Dec. 3. 2008 ·1 ;·59PM CBR Medical Inc.' No. 2478 P. 3/4 

;,'" .... , 

~ '-\ $jAT! OFWJiSHINGTOIII 

; DE!I>ARTMENT OF CORRECTIONS 

Medicirtal Use of Marijuana Verification 

01 r-ENCER I,D, OA'/iI: 

DearPresc)iber, 

By state statute the Washington State Department of C~rrecijons is charged With the responsibility to supervise some 

offenders after they have been convicted of a felony, The above 'named patient is currently under supervision by the 

Department Supervision is designed to help the'offender avoid·those environments or situations that lead to their criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Ac;cordlngly ifs usual' that the court or 


including marijuana This offender has claimed that they have a condition for which.the medicinal use of marijuana has 

been recommended. The below veiification 'is to determine the legitimacy of their claim. Thanl, you in advance. for your 

assistance. If you have questions please feel free to personarly contact the Medical Director of the Department at (360) 

725-8700. , /. 

1. . Is ~is patient under yo~r care . 0"Yes 0 No 

2. 



b. 

If the answerto question 2 is ·Yes·, does he/she have anorexia , 

If th'e answer to question 2a 15 "yes", does hefshe have weight loss 

Dyes .~. 

Dyes L.fV 

DYes E1No . 

3. 

Are you recommending medical marijuana for this pa~ent due to nausea and vomiting DYes 


a. If the answer to question 3 is 'Yes', has the patlentfaile,d to respOnd to conventional 0 Yes 


b, . If the answer to question 3a' is "Yes", please describe what those treatmE'.tlts were (medication, dOse, 

duration): 


4. 

B, 

5. 

6. 

. I 


. use of the oral synthetic formulation of marijuana. If the Department authorizes this patient's 


The patient's accompanying Releas~ of Information authorizes you to provide the. . 

Department with current and future information related to this issue. Do you agree to notIfy 

the Departmenrs Medical DIrector of ariy changes in your answers above 

DYes 

DYes 

DOC 14-053 (Rev. 7/31/0S) 

DOC 360:200 

PDU-665q-3 000447

I 

,[ 

.l. 

L 

I : 

I I" 

i 

pec. J. 2UUB l:~~PM GHR Medical Inc .. 

, r--- 

I i 

I 

I 

STATE OF WASHINGrON 


P,O. Box 41100 ~ Olympia. Washington 985'04-1100 

February 17,2009 

Spanaway W A 9838'7 

DearM!_ 

I received your request fromCBR Medicai, Inc., on January 5,2009, to appeal the denial 

of your initial Medicinal Use of Marijuana Verification. 

In the interest of public safety and protection of the cOmInUnity at large, I find your 

request for Medicinal Use of Marijuana, while under the supervision of the Department 


' 

. I would encourage yo~ to continue to prqgram in a positive manner, following the 

direction of your assigned CCO and your conditions of supervision. ' 

. Sincerely, 

Karen "Daniels, Assistant Secretary.: 


KD:rnd 

bC: Wendy Needham, Community Correction~ Officer 

Kelly Miller, Co~Corrections Supervisor 

Field Fil~ - DO~ " 


' 


----------------~CBR~e&~l------~-------------------------------------------- 

3115 E. Mission Ave .. 

Spokane, WA, 99202 

" Working Together for SAFE'Communitles" 

~ 

~~ recycled p.per 

PDU-6655-3000449

Dec.23. 2008 

4:41PM 

CBR Medical Inc. No. 2824 P. 1128 

I Fax 

CBR Madica8, Inc 

3":15 c. Mif>sion Ave 

Spdkan~WA 9G202 

.---~-.-----.. ".- 

-------,--.----....... ----.-.-.~ 

o Urgent 

Please Comment 0 Pions", ~eply .1:.1 Please Recycle 

-Comments: 

CSN. Medical,lnc. - 31·15 E. Mission Ave, Spokane, INa 90202 

Seattle Phone 206-774-64~3 Fax 206-41 8-0659 Spok~ne Phone 50g.:.24·8624 Fax 509-340-27'10 

lri-Clties Phone 509-416-267 F,~ 509~340 ..·r·!O Vancouvor Phone 360-530-6464 Fax 2.06418-6609 

CONFIDENTIALITY NOTICE:: This communication is intended fO!' the sole' usc of till:: indiyidual and 

entity tp whom it is addrASS~!d, and 'may conD'\in information thl.t is privileged, or Gonfidential aDd 

ex.empt from dbclosure under t>pp!i

Dec,23. 2008 4:41PM CBR Medical Inc, No, 2824 . p, 2/28 

. S'rATr;; OF WASHINGTON 

DEPAATMENTOF CORRecTIONs 

,AUTHORIZATION ~::OR DlSCLOSURr~ 

OF HEALTH INFORMATJOfll 

NAIVIE:: 

. ADDRESS: 

hereby author~e the use or disclosllre of my health information . 

organiza~ion is authori;zed to maKe the disclosure: 

(:. :) ..: I' ,..l.-i" j . _ / 

\ ~ I_I ;f.... _.. ,iI" !~ I. t: t. v ~ .... t" • 

·'''::~fi \ .J-;'" t.· d' ;~"l:[i·~::.::~~:~:;:;.-~)rJ/{~ 

.---.::,/ ') ,> ~ .. t·:·t ' : I. ..,fz..,.••/". '" LL).. ~'., ' . .!,".i.:

Dec.23. 2008 4: 42PM CBR M~dical Inc. No. 2824 P. 3/28 

.... ' '0' "'" . . nFFtNoernu. ,',p,J"A' 

~d)' ~ 

I;' . 

r iiOI.· STA"F.! OFWASHliI!GTON 

DEf"AR1'iI'lEN'r OF CORREc;TIONS 

Medicil'lJaH Use of Mar~ilLlal1l;a VeJl'Ufica1tiot1l 

--.. ,,- lIfIa·_-;·;· .. ~~ --'I 

.. -----.- )-.~ ... 

To be I'llled out by PrEls(~riber: 


By state statLite the Washington state .Department of Cqrrections is charged i.vith the responsibility to supervise some 

offenders. after' they have been aonvicted of a felony. The above named patient is cllrrently {Jl'ider supervisi(jr\'by the 

Department Supervision is designed to ilelp the offender avoid those environments or situatiolls that lead to tl)eir criminal 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court Or 

the Department of Corrections will impose a condition of supervision that the offender not use, or possess iilicit drugs, . 

including marijuana. This offender has claimed that they have a.condition for which the ,medicinal use of marijuana has 

been recommended, The belOW verification is to determine the legitimacy of theJr claim. Thank. you in advance for your 

assistance_ If you have questions please feel free to personally contact the Medical.Director of the Departmentat (360) 

7,5-8700. 

, . 

1. 

2, 

3, 

Is this piltient under your care 



a. If the answer-to question 21s "Yes", does helshe haVl1l ,anorexia 

b" If the answer to queslion 2a is "Yes"; does 'helshe Ilave weight loss' 



a. If tl:e an~wer to question 3 is ;'Yes", ha.s the patient failed to respond to conventiona~. (r. 

antiemetiC treatments . . - II/,J 

DYes 

~rN~~ 

!.;l~ 1a~Y-arN.~"f.1·'No 

/iin [lXgs.--·-8-NQ 

DYes 

. ".." 

la'No 

.J 

c. 

4. 

',.' 1\ \. 

", ~"I"... ""''::;~):"""" ________---'_--"":___--'-_ 


use of the oroll synthetic formulation of marijuana. If the Department ~l,lthorizes ~hiS patient's' 0 Yes 

use of medical marijuana, will you be prescribing ol11y the oral synthetic formulation 

6_ . The patient's accompanying Release of Info.rmation authori~e~ you to provide the _ 

{)epaltment with current and future info(mation related to thiS Issue. Do you agree.to notify 

the Department's Medical Director of any challge~ in your answers above . 

DYes 

Q-NO'" 

.... - 

01\lo 

DOC 14-0~:i (Rev. 713"1/08) 

OOC.3BO.200 

PDU-6655-3 000452

Dec. 23. 2008 4:42PM CBRMedical Inc. 

.. ,~ 

License#: 

- I.· ..· L";' r (./'" .. 

-4.~." ~ ;__ 

';':,_1_1. : ..... ~r:"-;' ___ 

,.r'/" .• ~.-:~;.~~ ..... ,.... _...... a ....... 

/ '; 

••• ~ .!. t"' ...... 

PreSClib€r's. Signli'ture 

License type: 

/,1 • 

Prescriber's Address :;; U.~~~::_. t·. . /l:'{ .~~ :'j / ,~_.~4.. \..'f Phone Number· 

Prescriber: please l'etll~~;'ii~'~~t~~~h~~~e p;t~~rii'~ ;2;~1~~fh~~'ormat,on to: 

No. 2$24 . P. 4/28 

,I" 

..- 

-_ ...... ---- 

.- .. _- .'---"~" 

Mediqal Director . 


Washington State D~partment of .Corrections 

PO Box 41'li3 

Olympia, WA98504·2113 

'.---.~---.' ._-._ ...... . . -----... ----- 

·ro be filled out by DOC Physician: 

I have reviewed this verification form and find that use of medical marijuana by'this patient' 

. (check one) .! 0 is D is not .'. . 

consistent with DOC Policy. . .. 

Physician's Signat\li~ • ':-. ---..... --_... .- 

Date' 

. Instructions to DOC Physician: 


1. . Email your finding above to the Assistant SSGretaryfor Comlllunity Corrections 

2. File this forrnand the i:\ccompanylng Release of [nformation hi Liberty as a'Community Corrections Health Recqrd .. 

Stl!tc law (RCW 70.02; RCW 70.24.1 05; RCW 11.06.390) and/Qr fadorai regulatiorn;. (41 CFR part 2; .45 CFR I"art 164) prohIbit 

disclosure of tlll!llnT'lrm

D.ec.23. 2008 4:43PM CBR Medical Inc. No. 2824 P. 5/28 


for Medical Purposes in Washingto.n State 

PATIENf NAME: _~_ __ ._ DATE'OF BIRTH: ~ 

I. Antoine Johnson , am a physician licensed in the State of Washington 

and I am treating the a.bove patient for a terminal illness or a debilitating condition as defined by 

RCW 69_51 A.01 0_ . . . 

. 1 have advised the above named patient about the poten!j.a~-{SkS and benefits·otthe medical use 

of marijuana. I have. assassec,l the above named p!'Jiieni's 

edical history and medical condition. 

It is my medical opinion that the potential ben~fjtiOf the 'Y dical use of marijuana may outweigh 

the health r1sks for this patient. . /,,-, I ' . 

Physician Name: ' Dr. Antoi~e J9r{~~'~n ' /'WA License Nu~ber: MD00039048 

. 1/" // 

. .'/ / 

Physician Signature:. I ......

J 

Dec,23. 2008 4:48PM CBR Medical I . n c, 

No, 2823 p, 1128 

!Fax .. 



i. , 

'Comment:!>; 

tl ,., ..., n nlnnt','\ ..... "'-nhr' n Pll'tl'lliF. RICVGI, 

._---.--'--'- 

/. 

"' 

'CBR MedIcal, Inc. - ·3115 E. MIssIon Ave, Spokane, Wa 9920;2 

Seal tIe Phone 206:..774-6493 Fax 206-418-6659 Spokane Phone 509-2,1\·2·8624 F:..x, 509-340-2710 

,Tri-Citlt:i6 Phone 509-416-2267 Fax 509·3J\0-2710 Vancowor Phone 3[30-635-6484 1= ax 206-4 '113-6659 

CONFID~NT1AI .. ITY NOTICE: 'This communication is intended for the sole lIse.tJf the Indivldual and 

entity to whom it is r~ddre5sed, and may contain· information that is privileged. or cnnfidential and 

exempt from disclosure under applicable law, You are hereby notified th6\t any disseminaiion, 

. distribution, or ctupficatlon of thi clJlTIffiunication by someone. oti1er than the intended' addressee or its 

designated "gent is strictly prahibtted. . 

Allll1formation is flrotected Under U.S. Fl;lderal Law 

PDU~6655-3 000455

Dec.23. 2008 4: 49PM C B'R ·M.e die a 1 Inc. No. 2823 P. 2/28 

OFFF.NCER ID. OATil: 

STAT~ OF WASHINGTON 


Medicinal Use of Marijuan2 Verification 

TO be filled out by Prescriber: 

:,. __ ... 1~~ F"® __ I 


t:ly Stale staIUte me VV nntl;rt'Il"ln'll'lntr nr ritll.,tinnr th..,t lQ'l1ri In thi-ir f'rimin'iill· 

behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court"or 

the ·Department of Corrections will impose a condition of supervision that the offender not use. or possess illicit drugs, 

including marijuana. This offender has .claimed that they nave a condition for which the medicinal use of marijuaria has 

been recommended: The below verification is to determine the legitimacy of their Claim. Thank you in advi;lnce for your 

l. 

725-8700. . . ~' 

1. Is this pati~n~ under your care Q Yes D No 

~. p.re you reCOlllrrll:lIIlJIIIY IIIt:I./fI,:CllllldiljudIlCirul !rio !o'",lic,·.LdLc6 t.::." dingl'l~:5i~ ofAoql.1!rod 


a. If the answer to' question 2 is "Yes", does he/she have anorexia r-tlf~ 

b. . If the answer to question ~a is .IIYes". does' he/she have w!;liylrllu~~tl/.r.;· 



UYes 

[3~-nNO 

Q.¥-e9'-~·"·B .. No 

DYes 

a. If the answer to question 3 is "Yes", has the patlent failed to respond to conventional 

antiemetic treatments #/A-. .. . . 

! 

b. If thf'l AnRWAr to !1u('::;;tion 3a is ·YeS". pl~ase describe what those treatments were (medication, dose, . 

duration): .. . ,if A- . .'. . 

c. What is the Plan~ed .schedule of chemotherapy IV I Pr 

~. 

. . 

4. 

. I:J. 

6. 

a.' . 

If y~~ ans~ered "No" to items 2 &. ~~. bove, whatis th~ reason you are recommending medicinal u~e of 

marIjuana.· ,,~ e . 

'" ~ . ~ "h.t ~ . 

. . '- "- • or-..... ~. • .c;... . 

t'l~Cl::,t:: fJ1\,JVIUC CYIUt;;I,'¥t;:i tJULJ"""II""'" J. l ..... !'IV~' 1_.1_ •• :... .... __ :_ •. cri_ r ... 1.1" .•• : ... 10 ... _ •• ,.. ....... fh,.. n'l1'IaI'Iir'\innll rrn "f 

marijuana. for this purpose ( ~. . \ • (\ .' . 

r 

j~-~. 

~c;.,.",~-~ 

YYT1JI6 on COmfflI,JIIIlY :101.11-'1;:1 Vh:lIUIl \ ).I", ..... '" J L"'" ...... J-' .. d", ..... ~ -P "'--: •• _..:~t_ .. _. ':"', ..• ~. ~-1-7- " ... 

use ofthe oral synthetic formulation of marijuana. lfthe Department authorizes thiS patlent·s . 0 Yes 

use of medical marijuana. will you be prescribing only the oral synthetic fcrmul.ation 

The patient's accompanying Releas~ Of Info.rmation authOfi 

7es you to provide the . . 

Department with current and future mformatton related to thIS Issue. Do you agree. to notify 

rhn nnn'irtmQnt'li Mli'lriiral nifFr.tnr of nnv r.himQ~~ in Y9ur answers above 

DYes 

/ 

[No· 

UOG 14·053 (Rev. 7131/06) 


PDU-6655-3000456

D ••• J!!I • .I!OOG I. 19 ~I.{ OCI'\ f,tyJI .. "",l 1,,'1' • 

...,~ ...... /,,,.1 'lv, J!02.!) r. ~/'f! .. O ••. 

.. " I' 0'" 

. "I . I " ,.oIJ'. 

. Ii' .' ~ '. ",,:,,~' ,.l f ." .,,'P'.' r,;~7......1 

/~ \v 

. la' \ /. .;". / (../:.,. ,.1 G' y- 

. \ "." .', ,'j ~ J~'/ 1"/ 

A', v-..{. , ) "n"" )\,_ ..1 ' ,. '7 ' /~ ,/ , 

Prescriber's N'ame ('n!) • . ..... '-- Prescnber's srg~foii , /L)ate', .n • 

, (f""f 0;0, C. "">1 t.l e''-f t /I ' f 

License #; '-'. ~_. l) , If'cense type: _fl_11...,;0.:::....... ____ _ 

Prescriber's Address.~ .. (.. PJl...· ... (V'\,z;Uvs.\ ~~j':::.: .... ::..._ . Phone Number .r c '1 2, tt - r!.~ ~y 

, j17 ,,\'\ "'".. V'r-~71. ' . 

Prescriber: plea~e return thls form aAd the patien~ Release of Information t,o: 


Health ServIces Division 

Washington State Departmetlt of Corrections 

PO Box 41123 

Olympia" WA 98504-2113 

.. - 

To be filled out by DOC Phy~ician; 

I have reviewed this verification form and find that use of medical marijuana by this patient ' 

(check one) lOis U is not ' . 


' 

"PhYsit;ian'~ N~e (Print) .. -----•• ,--- 

-PhYSician's Signature •.. --------00 ._- 


, When form is complete; 

1. Email your finding above to the ASSistant Secretary for Community Corrections 

2. File this form and the accompanying Release of Information in Uberty as a Community Correc~ions Health Record. 

Stats law (ReW 70.02; RCW 70.24.10.5; ROW 71.05.39Q) and/orleQt;!!'a1 regulations {42 CFR Part 2; 45 CFR Piiltl.164j prohibil 

(ilsclosliFe of this information witho\lt the spe~ific written oon!Wnt of the p$rson to whom it per1

Dec, 23, 2008 4: 50PM CBR Medical Inc, 

No,2823 p, 4/28 .' 


DEPARTMeNT OF CORReCtIoNS 

AUTHOA.IZATION FOR DISCJ...OSURE 

OF HEALTH INFORMA liON 

OFI"ENOER ID. OATI\: 

" 

I,~~.~, .._ 

___.:.' hereby authoriZe the use or disclosure of my health information 

01. dOl.cribild bOilow. The folt"wjna inrihnrill;:!1 or nroAni7Atinn if; AII~hnri7f!rll'n !nAirA thp. ciiRr.ln:mrp,· 

NAME: 

ADDRESS: _______ 

-------._-------_..........- 


-----_ .... -.,------ 

Rurpose for disclosure: ____________________ _ 

.-------.-.~ 

I understand that the information in my health reeord may include information relating to sexually transmitted 

infections, Acquired Immunodeficiency Syndrome (AIDS). or Human Imri'n.inodeficiency Virus (HIV). It may also 

include information abo~t behavioral or mental health services and treatment for alcohol and drug abuse .. 

This information may be disclosed to a.l1d used by the following individual or organization: 

NAME: 

ADDRESS: ________ ._.,, _____ _ 

. ( understand that I have a right to revoke this authori,alion at any time. I understand that if I revoke this 

authorization I must do so in writing and present my w~itten revoGation to the Health Information Management 

Department. I understand that the revocation will not apply to inforqmtion that has already been released in 

response to this authorization. Unless otoerwise revoked, this authorization will expire on thl following date, event. 

or condition:' 

.~.__{if left bla~k, authorization will expire six {6} months from signing). 

I understand that aJ,lthorizing the disclosure of this l1ealth inToMation is vo!untaiY. I can refuse to sign this 

. authorization. I need not sign this form in orderto assure treatment. I understand that I may inspect Of copy the 

information to be used or diSClosed, as provided in CFR 164.524 and RCW 70.02. I underatand that any disclosure' 

of information carries with it the potential for an unauthorized redisclosure alid may not be protected by federal a~ 

state confidentiality rules, If I have questions about disclosure of my health information, I may contact the . 

RHIT/designeeofthefacility: ____._"'""""-___,,__. _--,-- 

Signature GIl 1'a1lcnl 

(Qo not sign If form is not complote) 

Date 

(Palip.nt to complete) 

Sociel security Number. 

Dale of Birth 

DOCNumb~r 

5isn!!t\lre ofWlIr1~'" 

Date 

~·WI. lAw rrn!W ~.!I~. IIWI' rO,:4.11l$, nCI)' ;>l.OS.JPO) ",.oL1,,,'fobNJINOgWM..,,, (d rF'11 Pm't 7:.1'l rFR Parr IMJ IIrn/llbiuf.i.!t;I(}··~1'IJ 

"[litis ilJ!imtlotian witholtl lit_ .'pecific lrrillll1 ~ntlJ'l1t ollh. pCfJO/1 to ,,/rom it pertain.,. or"" ,,(hu,";,fE permillcd by kilO. : 

IlOC l~oS(II!iI19/2008)PCll uOC3lIO.200 OOCUIlO,020 OOCQ4o,Il20 OOCorO,IIJl lEf;;/11 

PDU-6655-3 000458

Dec. 23. 2008 4: 50PM CBR Medical rnc. No. 2823 P. 5/28· 

Documentation of Medical Authorization to possess Marijuana 

for Medical Purposes in Washington State . 

PATIENT NAME:~~_ 

DATE OFBIRTH:~ 

-, ..... _ ..... -- .... __ .. 1---- - r··.I-r-....... u __ •• ___ .0 ...... - - ............ ~ 

. •.--..... tt .. ~ •• 

and 1 am treating theabov.e patient for a terminal illness .or a debilitating condition as defined by 

RCW 69.51A010. 

_.."."... ~~- ..... 

1 have advised tile above' named patient about the pot~r.ltiar risks and enefits of the medical use 

of marijuana. Illave assessed the above named gatlent's medical h· tory and medical condition. 

It is my medical opinion thatthe potential benefitS' of tile medical u of marijuana may outweigh 

the health risks for this patient.,. / . 

Physician Name: Dr. Antoine 'John'son . WA Lic~':e Number: MD00039048 

.J 

" ",ll' 

. _.rI',.~,,,,. ._' . 

Physician Signature: ___-;"-_____----:;>-',_ 

•• c:I-! 

This tecommandation eXPireJ.~n:. . 04/13/2009/' /':' 

,/' . 

" 

Risks !md benefits of medical marijuana / 

Date: ___ 04_/1....;3_/2....;,0_08"--__ _ 

Under Washingtoillaw, the use of m ,ieal m.aHjuana is now permissible for some patients 

with terminal or debUitatlng illnesses. lie la~(egulaUng this (RCW 69.51A) allows physicians 

to advise patients aboat the risks a benep-rs of the medical use of marijuana. 

Tl1e medical and scientific evl .nee s>lPPorting the use of medical marijuana' remains 

cantroversial'in the medical co unity/Not a/l health care providers believe that medical 

marijuana is safe or effective. d so,me providers fee! that it is a dangerous drug. 

According to the washing~n ~te law the be!leflts of medical marijuana may include 

treating nausea and vomitin ]¢n ~hemotherapy, AIDS wasting syndrome, severe musc:le 

spasms from multipie pciel'o IS or othe,r spasticity disorders, gl



OFFICE OF THE ASSISTANT SECRETARY 

P"O, Box 41126· Olympia. Washington 98504-6504 • (360) 725-8796 

FA~ (360) 586-0252 

September 17,2008 

Spanaway, ViA 983S7 

DearMr_ 

I have been asked to respond to your September 14, 2008 'letter' addressed to Dr. 

Hammond. You write to request the reaspn your application for medicinal use of 

marijuan~ was demed. 

The reason listed on y~Urapplication is ~ follows: "Denied, nqt consistent with DOC 

policy." G. Steven Ham!!,:gE.~L~,· . .I~ .. B9Ji~Y_~F..aF.lmo!:~ i~_!;~f~~gJ2"i~"~~9~..Q,9!,._,_,_,, 

Community SupervisioI), of Offenders. You can locate a copy of this policy on our Web 

site at http://W'i\rw.doc.wa.g:o~/policies/. 

Should you have further queSTIOnS, please feel free to contact me at (3 60) 725~8 847 

and/or sksmith(ci),docl.wa:lZov. ' , , 

Sincerely, , 

Q~ 

. >-': " " 

\J. -' ..' '. 

. (,,~ith, Executiv~Assistant . " 

. Community Corrections Division. . 

cc: 

Steven Hammond; MD., Director of Medical Services 

PDU-6655-3 000460

09~14-2008 

. RECEIVED 

SEP 17.2008 

Dr. Hammond 

Sherri K Sn;lith, Executive Asst to 

Karen' Daniels, Asst Secretary 


MS:41126 


Olynipia, WA98504-1126 

360-725-8.709 .' 

Attn: Dr. Hammond and Sherri Smith and Karen Dimiels 

Dear Dr. :Hanimond, 

Dated Tuesday September 02, 2008 it' appears that you have denied 

. medicinal use of marijuana. I would like to know the reason for 

: your my under RCW 69.51 A Washington's Medical Marijuana Law. 

Please send your response to me in writing before. September 28 th , 2008 so that I may proceed with this 

fWrther. . 

PDU-6655-3 000461

I 

I 

, Smith, Sherri K. (DOC) 

From: 


Sent: 

Tuesday, September 02, 2008 8:30 AM " 

To: Needham, Wenqy M. (DOC); Miller, Kelly L. (DOC); Vernell, Eleanor D. (DOC); Fiala, Anne L. 

~ 

Subject: ____ Medical Marijuana Case 

Dr. Hammond has denied the medicinal marijuana request for 

Sherri Smith, Executive Assistant to 

Karen'Danieis, Assistant Secretary 


MS; 41126 

734$ Linderson Way SW. 

qiympia, WA 98504-1126 , 

Phone: 360-725-8847 

. . " 

Even if you 're, on the right'track, you'll get run 6ve~ if you just sit there. ~WilI Rogers, 

1 

PDU-6655-3 000462

Smith. Sherri K. (DOC) 

. From: Distefano, Monica J. (DOC) 

Sent: 

Tuesday, September 02,20087:43 AM 

To: 


Subject: 

FW: Medical Marijuana Case 



i-Saren Daniels, Assistant Secretary 


7345 Linderson Way sVIi 

Tumwater; WA 98501 MS: 41126 . 

(360) 725-8796 . 


From: 

Sent: 

To: 

Subject: 


Wednesday, August 27, 2008 6:10 PM 

Distefano, Monica J;(DOC) 

FW: Medical Marijuana Case 

Karen Daniels 

Assistant Secretary 

'Community Corrections Division 


. 7345 Undersan Way SW 

Tumwater, WA 98504 

Office: 360-72.5-8787 

Cell: 360-791-7768 

Fax: 360-586-0252 

. email: krdanieis@docl.wa.gov . 

From: 

Sent: 

To: 

Subject: 

Hammond;G. Steven (DOC) 

Wednesday, August 27, 2008 4:09 PM 

Daniels, Karen It (DOC) 

Medical Marijuana Case . 

I denied a request for mm· 

G. 'Steven Hammond PhD; MD, MHA 


Health Services Divisio'n 


POB 41123 


360-725-8700 

1 

PDU-6655-3 000463

~- 

6S/2e/26ee 12:ae 2538475797 PAGE a4 

• '. 

OFFENDSII l.g. gllTA: 

I' (~ ~~l~~~~~~~HcGJ~~cnoNs' . 

M~dlclnal Use of M.rijuana Verification 

~C_O_:_· __________________ ~ __ ~~liIIIf~:_inn __ ~ ____-JI.D.O.C.N.u.m~~ 

To be fllied out by Prascrlbar! 

__ r ____ ~'1 

Dear prescriber, . 

. By state statute the Washington State Oepartment· of Corrections is chargedwtth the respo.nsibmty to supervise some 

offenders after they have.be..n.c=~lcted p~ ~ felony. Th~ above named patient Is c,urrently under supervision by the 

Department Supervision Is' designed to help th~ o~ender avoid those environments or sltuatlen~ that lead t~ tJ:1eir criminal 

~t;avior. Often llfi!:it dr\.lS uee 15 a contributing facler han indIvidual's crimloallty: Aa:crdingly It's usual. tMt rl'le tourt or . 

the Dep~rtment of CcrrectiohS will impose a cendition of supervisIon that tha offendtlr not use, or possess illicit drugs, 

including marijuana. tnls offender has claimed that they have acondl~on rorwtllch the medicinal use of marIJuana /'las . 

l:Ieen prescribed. The below verification Is to determine·the legitimacy of their olalm. Thank you in adVance to~ your 

assistance. If yOIl have questions "Iea~e hlel free to personally contac;t the Medical Director of'the Department· at' (360) 

72.5·8700, i .. / . 

. 1. 1& this patient un~~r yOl,lr oara ¢' Ves 0 No 

. 2. Are you prescribing I'fledical marijuana for his ~itlent due to &l diagnosis of Acquired 

Immunodefioleri~y Syndrome (AIDS) . . 

Dves 91fo 

3,' 

;, If the answer to question 2 is "Yes', does he/she l'Ieve anorexia Dyes c:;;}rq"a 

b. 11 the anMf to question Za Is "Ves"/does he/she have weight loss DVes DNO 

Are you prescribing' mEldic~1 marijuaMa tor this patient due to' nausea 'Sr1d vomiting aSSOCiated 

with cancer chemo1tI(;~rapy . DYes ~. 

I!. 11 the answer to quc3tion a 1$ ·Yet!.", has the petlentfalled to rOGipond to conventional . 

a~tiemetic treatments .. . 

Dns . !5No 

b. If the ansWer to Qumon :3~ is "Yes·, pleaSe describewhat these treatments were (medlC!aUon, dose, 

duration): . ': . '. .' . . . . 

. . . 

e,' What is the planned SChedUle qf chemotherapy 

. " ~ . . 

. 4:Whna of'! cgmmunlty 5upsrvis.ion (·paiol~~' the Department of COIT~tiOi1S enly authcrizl!I! the ~o 

use of!:l1e flt3i synthetic formulation of marijuana. If tI1e Department authoriZes this patienfs 0 Yes I!:::l NO 

. 1.15" af medical marijuana, will you be proscrtblng only tl'Ie orsl synthetic fgrrnuletlon7 

s. The p~ij~nrs·accompanying Release of Inform~~on euthQ~Ii':es you 1i:l prOvide tha 

Oepartment with current an~ future information related to this issue. 00 you agree to notify O· Yi • n...rr:;". 

the Depertr:nent's Medical Drrector of any change~ In your answers above . as. ~ I.I!r l'~...:. A: P. . 

----..ro(,-e.lo't.-O":IoJ-7....-'-3·-.t)!j~-/.oJ-i41..-G:.ot~A-.R-q_~-Io-~.y"~";;j-U>,.r.J.¥i-i·~""J:f~-~-· 

~. A..}.f0. ott"''";..,;, . p~~l C'i)1.t'l!t....~ IVaI ..... BV".· l.i 1-1(f'.' . d. • . 

o '" Nol). ~J)'F~rs\Jg~4i J . .. l/~~ 0. r 

i~_ . 

~OOIZOO 16 OLLZO~BSO~ XV~ LL:ZO BOOZ/SZ/80 

PDU-6655-3000464

2538475797 

FlAGe: 62 

STATi O;:WASHING'1'ON 

DEPAR110IENT OF CORRECTIONS 


OF HEALTH INFORMATI.ON 

.To be filled out by ceo: 

OFFEllOI!R Le. CATA: 

~ _______ ,--_, hereby authorize the Yle or dl~osu ... of my health lnformatlon 

The following individual orofisnization fa authorized. to make' the disclosure: 

ADO~s!~ 

'jfi ~~~ i2~:Ji~- ~~f~ ~~ j'~C)~' 

. ~C·lI.n.Jk...J::$,J. ~ c:t~Q. 2 . . 

, .' ,thr£:. (Pi; 'di:-.. ~ t ~~; 

. - T!'t~ type and date(s) of information to be used or disclosad is a.s follows: 

, 1. The aceompallyln9 MedIcaL Martju~na JuStlflc;rtJon 10rm. . 

_. 2. Any other information requested by the Medic.al Dlrec;tor, Washington State Department !'f CorrectIons. 

" related to my prGScrlptJon for med.Jcal mariluana. ' ' ' , . 

Purpose fcIr dlselQ$~re: To d.etermine the legitimacy of the patient's ctalm of a ~eed to use medical marJjUana 

I understand that the inform~tion In my health record may Include InfOrn:latlon relating to sexiJaJly'transmftted 

"infections, Acquired Immunodeflctency Syndrome (P,.ICSl, or Human Immunodeficl,noy'v'lru6 (HIV). It may also 

include lnformaflon about behavioral or mental health 'I=r:-.rices ami treatment for alcohol and dlllg abuse:, . 

-- This lnformaUon may be dledo-sed to and used by the -following Indl'lidual or organIzation! 

NAME: Medlc:ar Director 

ACORf:SS: Wa5hlngton State Department of CoTTGQtiona 

Fax 360 586-9060- 

.' 

I u nders!end that I have a rl9nt to revoke thl~ ~uthorilatio". at any time. I unde~lend that If I rev~ke this, 

. :alithorization I must do so in writing ~nd p'~elJtmy written revix:¢.ion'tc! the Health !nfqrmati6n· Management 

Ceparlmen~ I· understand that th~ revocatioo will not apply_ to Information tHat -Me already been releaSed in 

response to 1tIis authOrization. Unless otheiWise revoKSd, ij1\s au!l1ori;z:ation will expire 01) the follOWing date, event, 

or condition; At the. tarmjnBtI~n of the, (if lett blank, authorization will exPire six (6) months from signing). _ 

patient's supervfslon by the - 

," . 

Wlahl~gton St&~ Department 

of eorrectionc . 

I understand that authorizing the disclosure ~~Jt~Ji!Llnto1!natlon Is vo[un~_ • .ig~rue.6.l$~_tp_sJgnJ!liliL.... _____ -"--_ 

authorization. I need !'lot sign this farm In order to assure natmant.- I understand that I may Inspect or,copy the 

Inro~tlon to be usee! or disclosed, as provided In CFR 164.~~4 and. RCW 70.02. 'understand t!'1at any dlsclO$ure. 

of Informellon cames yJltti It the potential for lin unauthorlzaG redlsdosl.l1'S at'Id may not be prot=ctaell:ly federal or 

S1ate ponlidentlall~ ru,les. If 1 have' questio!'l$ about disclosure of my health Infcrmation, I may eontact the . 

RHIT/deslgnee of the facility: -'n"""a=-_______ --:--__ -..:.._~_'___ _ 

_ po~ 13--035 Rav, O!l1~Joa) OO,C SOO:020DOC 840.020 DOC 6(0.020 L5QAL 

GOO/LOO~ 

PDU-6655-3 000465

February 17, 2009 

STATE OF WASHINGTON . 


P.O. Sox.41 i 00 • Olympia. \~/ashir1gton 98504- i 100 

Spokane, ViA 99037 

DearMr._ 

I rece~ved your request from CBR Medical, Inc., on January 5, 2009, to appeal the denial 

of your initial Medicinal Use of Marijuana Verification. 

In the interest ot'public safety and protection of the community at i'arge, I find, your 

request for Medicinal Use of Marijuana, while under the.supervision of the Department 

of Corrections, is denied. . 

I would encourage you to contln~e to program in a positi~e manner, following the 


Sincerely, 

Karen Daniels, Assistant' Secretary 


K.D:md 

cc: Jefferson Overholster, Community Corrections Officer 

Etta Molett, Com~orrections Supervisor. 

Field File - DOc-. . 

Physician's Office: .' . 

Attn:. Meiissa Leggee 

CBR Medical. . 


Spokane, ViA 99202 


PDU-6655-3 000466

Jan. 4. 

2009 12:39PMCBR Medical Inc. 

No. 2927 P. 2 

Hello and good day. 

The following leHeris wriHenon hehalf' 

Wac;hingiol1 State Deparlment ()I'Correclions 

iii an 'offender' within the 

our client / patient 

On 12-08-2008, G. Steven lIammonde, MD (Medical Director of the DOC) responded to Mr." 

" to use m

Jan. 4. 200912:40PM CBR Medical Inc. 

DEC-3U-200B 01:3B PM DOG GC u~p StU 360 586 0252 

I 

-I 

STAl'I1ClF WASHINGTON 

DEPARTMENT OF' Cmm.ECfYONS 

P.O_ Bt •.\ 41126· !"llmplil. W •• hlnY!£J1I '18,(14-1 126 

FACSIMILE TRANIHIlITTAL SHi3I'iT 

No. 2927 P. 3 n"O 

P. u! 1$ 

.............. 

iO: FROM: . 

NisilS!$$i I\IIcGh~e 


-CO-M-PA-N-Y:- ..•.-----~~-- DA.TS: . 

DECEM8ER 30,2008 

FAX NlIil.tIlE:R: . 

509·340-2710 3 

TOTAL NO, OF PA.Gl:S INCLUDING COVER: 

SENDER'S PHONr;. NlIMBER: 

360..7:(.5-8700 

--'-~-----~-/!-t;-N~;'S FAX NUMBER: 

360-586-0252 

----, -- ,,--. -- ,--======---===--- 

IJ IIRCCN',' X FO~ REVIE~ 0 PLEASE C()MMENr [J PLEAS~ RePLY D pl.F.l\se RECYCLE 

....=:= ...... ===="""""==' __ .. -= ...... ia=:==0111=====-_~.,.=-== __ ======= 


Executive S~r.retarY 

360--725:-8796. 

PDU-6655-3000468

Jan. 4. 2009 12:40PM CBR Medical Inc .. 

DEU-JU-cUUH Ul:JH pM DUG GG DtP ntu P. 4 . n",g 

Nov. 26. 2008 4:52PM. COR Medical Inc. 

380 586 0252 

No. 2927 

No. 2426 P. 5/13 

p, lJr. II 

to be flilfild out by Prescriber: 

-- 1PateOf:i;jh - ~mber ._'-J 

~_I"- __ . __ 

Dear P(JGCrlber. . 

Ely stale gtatute the Washinalan state Department of COrrecliOflS Is chw>lsd with the resOOhliibilllJl to BI!P€!fV;S() t;llnw 

offendors after they have been convicted (If R. f~hmy, The 3boVa haulod patient is clJITentiy under supervision by the 

O~partment 8L1pt.rv~!Q!1 ~ designed to tlEllp the orrel,der aVOid those environmenls or situations that lead to their criminal . 

·bel1aviOt'. Often ~lic!t drug use Is a contributing fattor in

Jan, 4, 2009 12:41PM CBR Medical Inc, 

DE0-ju-~uutl·Ul·;qu rrt Duu uu v~r btU 360 586 0252 

Nov',26, '2008 4:52PM CAR MnJical Jn~, 

NO,.2927 'p p, 5 . "l,."G 

, U;I l.' 

......... 

Medlenl Dlrl,.l(;tor 


'. WashIngton State Deparlm~nt of Corte(l{lona 

PO 801\411:1.3 

Olympia, WA9S504--21.13 

To lilt filled om liy OOC Physician: 

I have reviewed·this vcriftol'l!lon fo!!!! ~rt iin~ !hilt Ulla gf mr.:dlmdllJll:uiJUfll'lhl lly this P!ltl~flt . 

(chack.o"!!) I [J ill []ffs not . ~tJ ..' . 

MrwJtcnt wilh OOCPolicy. . f.:J~A. 

~·;Skv~ ~~'\.(Mt\). 

(l6IkfM-""-""~ .. v~~, .. ,,L 

-I'hyi!l~an's Name (t'r~ -- .- " pl'lsiclan', Sigrr~ .- '- 



1 , ~mail your finding "",bovs ItIlhe Assistant Secretary for Community Corrections 

i 

File this form and the ~ccompanying Release of Information in '-lPl'!!'ty fllO a ComrOlIOity Corrections HeelIt!1 Hm;nlll. 

" 

... 

• l!lb!t~ I~ (RCW 70.112; R~ 10,24,105; RCW 71.0S$O; andrarreder.ill r~glllatlom; (42 CFR Pori 2; 4S CF~ f'lII'l184t prQ/libil 

I;{isc!cs\lre 0' Ihb inf..rmlltion wit/1aut tho IPlIcifi,;;WIit1l1n ~QI1~'\1. nfln~ Il",.nn towh"", II ~flru.im'. Dr 1m aU1IUI'1I'';o,I 

permitted !!y Iav;. 

DOC 14-llS3 (Rev. 1(J1/08) 

\Joe 3!l(l,IWU '. 

PDU-6655-3000470

Jan. 4. 2009 12:39PM CBR Med i ca I Inc. No.2927 P. 

311fi 1::. Mit;~jinn Avrj 

Spokan8, WA IlGO 

i . 

-'-, 

I 

I 

[. 

i 

CBR Mediunl, Inc. - ::111 ti E. Mir;r;ion !\Vu, lipoki:1I In, VIla U020 

:·jf.8ttlu [li1nno ZOf:''(l.-1·Q4H:l rw

Dec.30. 2008 12:20PM CBR Medical Inc. No. 2867 

P. 1 

,- 

3115 E. IIIl1ssian Ave 

Spokime. W/\ A92,02 

,~o~ t'lliJl(~ uts-efantL., r~'om: rne.\i~)C:'iL@ ~ ... 

. ~~...cuO~t'ia.:-.cY2.b.L D~ - (J~) SCI / Q' S",,- 

,~~Q"ec 6l.oQ '7.25..~ QF1 LL F~_ 

,_;1, 

Re: 

--- 

I 

I- 

I 

! 

clm Mc(lil~al.lflc;, ' :.1'1'151-:, Missic.lf'I Ave, 8ppk.me, Wf.\ 887.D2 

SO.llUA PhDIlC'! /.08-774 (;483 ri'lX 10G-4iB-6G59 Sp(Jl~unAl-'hll[\l~ !i(J\-)-2.,12.-,f.l(-j;iA rw< fiml-3tto ..,71U 

'! n-Citiet; I 'hone 5mJ-'! 10Yl.07 F;JX h09-3f\{1 .. :mo, VanCUlIVp.T Phu(lI~ :1('l(J-63[i .. 64(i4 rolX ~()(-'\ '18 [joti£) 

CONfiDENTIALITY NOTlCF.: TIlls mmrnLlnir.ation i,; intentied fnr ttlQ $018 usc nf the inrlividuaJ ;:md 

entily to wllorn-_it is ilddmSfjAIl, ';'Iflti lTIay tJr)lltaininformatiun Hlat i:.l privilegl)d. or c(JfllirJ!'!nticll ;,)l1d 

exempt from _ disr.;I()\~ul13 under tJpplicabll) law, You am I-Iflreby nntifled ll'lr~t any LiiRsernin;~tion, 

riisjJ'ibution, 'nr'duplicrltion 1)[' this c:nl11munictllion by sOllleone other U l;1n tho intandclj ;')(lrjres;.;np. or II!:; 

dtlSinnaioti a~lent ic~ Rtrictly prohibiled, - - , 

PDU-6655-3000472

Dec. 30. 2008 12: 2'1PM CBR.Medical Inc. 

No. 2867 P. 2 

'Orrt!NDeR I.ll, L1A I A: 

STATE OF II'JASHIMI!ITON 

DEPARTME~OF CORRECTIONS 

disclosure of my health information 

or organization is authori;2:6d to make the disclos!Jre: 

'l:: '") ,( 

NAMf:: C i e··,,· 

.... L)' l~'-' . "'~ . e ('1 (- c_ .~ .x .-\,. f\' C 

.-:;:>. '- -:•• ' '. 

ADDRE:SS: 

~.' "!"4': 

•...;> \ \ ~., k ,4,'1/ ~;;" ~J\C::1t:, __,_ "v-L 

..,..... -:-R;:L ... ) .,. "- .:-~ t l ·,110 I.l) , t ',.'" ,.\.._) 1.,,,- n" ft \.~1 'i~' (''\.i r· .!.~:. 

" .. . 

--'----. ...-,----- 

._--... _-- 

! understand that the information in my health record may include information relating to sel



P.O. Box -tI 116' Olympia. Washingtoll 98504-1126' 

FACSIMILE TRANSMITTAL SHEET 

TO: 

Melissa McGhee 

COMPANY: 

FAX NUMBER: 

509-340-2710 

PHONE NUMBER: 

FROM: 

. Monica Distefano 

DATE: 

DECEMBER 30, 2008 

TOTAL NO. OF PAGES INCLUDING COVER: 

3 

,SENDER'S PH,ONE NUMBER: 

360-725-8796 

SENDER'S FAX NUMBER: 

360-586-0252 

o URGENT X FOR REVIEVV .0 PLEASE COMMENT 0 PLEASE REPLY' 0 PLEASE RECYCLE 

NonS/COMMENTS:, 

Monica DistefanO . 

Executive Secretary 

360':725-8796 

PDU-6655-3000474

NOV. LO. LUV~ '1:'LYM . \'~K IVlea.lCal lnc. 

No. L4L~ 

P.· ~/lj 

~..,tlur~ 

~ 

I' :\. STATE OF WASHINGTON 

OSPARTMENTOF CORREcnONS 

Medicinal Use of Marijuana Verificatioal 

10 he filled out by Prescriber: 

.. 4 

-j-oate of Birth -.- IQbc Number ---J 

_88___.1_._ 


By state statute the Washington State Depflrtmcnt of Corrections is charged with the responsibility to supervise some 



behavior. Often illicit drug use is a contributing folctor in an individual's criminality. Accordingly it's usual that the court or 

the Department of Corrections will impose a condition of supervision that the offender not LIse, or possess illicit drugs, 

induding marijuaria. This Offender has claimed that they have a condition for which the medicirial use of marijUana has 

been recommended. The below verification is to determine the legitimacy of their. claim. Thank you in advance for your 

assistance. If you have quostions please feel free to personally contact the Medical Direclor of the Department at (3SQ) 

725-8700. . . / 

1. Is this p~tient under your care . ~s D No ./ 


Immunodeficiency Syndrome (AID.S) 

a. If the answer to question 21s 'Yes", does he/she have anorexiol 

b. 

If the answer to questIon 2a is 'Y~s·. does he/she have weight loss 

3. . Are you recommending medical marijuanc\ for this pallent due. to n~usea and. vomiting 

!:Issoda.ted with cancer chemotherapy 

a. If the answer to question 3 is 'Yes", has the patient failed to respond to conventional 


b. 

UYes 

~ 

B-ns-·~o/':J,r:}. 

D~.es--B-No 

If the answer 10 question 3a is "Yes", please de!)cribe wt)at those treatments were (medir.ation, dose, 

duration}: .... [ " . 

~.~ .6r 

. 

I \ 

DYes ~. 

t'11l' 

O'l';;s-' .--+F.-+-I~ No ~ 

4. 

c. 

What i.s the planned schedule of chcrnotheralY 

. . .N\~ 

If you answered "No" to iterrls 2 &.3 above, what is the reason you are recommending· medicinal use of 

marijllana __ ~ ~ h- L ~ ,-' .L '\ \.. ' 

. .' \ r~ \ r.-.:v.' () "\. " ...... ,-r ~(.-\ c,..> e.. (' r,;...."'. ., 

a. Please provide eVidence published in a peer-rcvieweq scientific pub'liC

Nov.2[ 2008 '4:52P~ CBR Medical Inc. 

j .,............ /., 

No. 2428 P. 6/13" 

••,,0'," / I .:/,J 

0>.,...... /" I' I· 

, ••,., ,. ',/ . I /~/ •••• 

/" . --.-;'

Nov. 26. 2008. 4: 50PM CBR Medica.l Inc. 

" . 

No. 2428 P. 2/13 

STATE OF WA$HINGTON 

DEPARn1e;~AT OF CORRECTIONS 


OF HEAL'fH INFORMATION 

fJl-l-l-NI )~~ I n, rJATA: 

I,' 5p~ncer Cunningham Aka Clawson '.. ,_, f1ereby authorize the use or discfosure of my health information 

as described below. The following indIvidual or organiz!:1tion is authorized to make, the discfosure: 

N,lI.ME: --L: 8 ,e.. Pie,); ,c,,,, I .::tf1('~" _ 

, ,.}' (1 ' 

ADDHESS;, -7!, { I .t...}' l:, _",,,.!,-p,' ~'S ""~. :',') 1'1 .. It-. lit> 

~-')(.1 t) t: Cr.,'7 (.i , Id G- '1 .. t:) .P. D .2 

( - 

f understand that the Information in my 11ealth record may ineillde information reh"lIng to sexually transmitted 

infections, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunode'ficiency Virus (HIV). It may also 

in,elude information about btlhf:lvioral or mental health services and treatment for a,lcohol and drug abllse. 

This information may bel ~isclosed to and used,by the fJ 

IOWI~~ividLial ~r organization: 

, , NAME:.. ~ -Ii. ,.,. t.l (I. (;, tJ /1 , (! c.. t:J, ' 

ADDRCSS; l2.-p+ .. of :(~,,.-r"o("C-f;":::·'l,"j., s1kt!:... 

I understand that I have a right to revoke this authorization at any time. I understand that rr'1 revoke this 

., authorization I must do so in writing !:1nd present my written revocation to the Health Information Management 

Pepartment 1 understand that the revocation will not apply 10 inft;>il11ation that has already been released in 

response to this aU7hi7.Etl' Unless ottlerwise revoked, this C'lLlthorizatien wiH expire on the following date, evenl, 

or condition:.d2 -==-3 c. "1', Jif left blank, authorization will expire six (6) months frOrrl Signing). 

. I· . 

I understand that authorizing the disclosure of this health information.is voluntary, ' I can mfuse to sign this 

aLlthori,atiol1. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the, 

infomlation to lit: 'used Oi diSclosed, as provided in CFR 164.524 and RCW 70.02. ! under.;lr;lnd tlwt any disclosure 

of information carries with it the potential for an unallthorized redisclosurc and may not be protected by federar or. 

state confidentiality rules. If I have questions about di::;closure of my health infom18tion, I may contO OOC 670.020 L~r.AI 

PDU-6655-3000477

j 

i 

! 

I 

Naif. 26. 2008' 4: 51 PM CBR Medical Inc. No. 2428 P. 3/13 

Documentation of Medica! Authorization to Possess Marijuana 

for Medical purposes In Washington State ' 

i 

! 


DATEOF'8IRTH:~ 

I, , Antoine'Johnson ,am a phy~ician licensed in the State of Washington 

and I am treating the above patient for~a termi~lIness or a debilitating ,condition as defined by 

RCW 69_S1A.D'lO_ " " / 1 , 

I have advised th/' above named patient al1out, th~ potentia! risks and benefits of the medical lIse 

of marijuana_ [have assessed the abov~ named ,patient's rnedical history and medical conditio('l_ 

It is my medical opinion that the potelJ{lal benefits of the medical use of marijuana may outweigh 

the health risks for this pl!itient' .' J , I 

;' 

Physician Name: _--.:O::..:f:,.;. A,-"n""t,:::oi::.;.ne::.,' .:..Jo~h.::.n:;:::so=.:n-,:-+/_~ WA License Number:, ___ M_D_O.,..O_03_9_0_4_8 

'/ :./j / 

;. l' t 

Physician Signature: __ -+1_ ---i-'" -+{ _____ ~ 

i ,/ / 

This recommendation expires' 'tln: OMO~J2009 

, . ! / 

Date: __ 1.:.....1_fD-'-2J:..;;:2'-O.::...;O~ ___ 

Risks and ba~efit,') of modical marij~ni , 

, Under Washington law, the use _.of rp{edical marijuana is now permissible for some patienfs 

with terminal or debilitating iIlnessps.jilie law regulating this (RCW 6R51 A) allows physicians 

to advise patients about the IiSks~nd benefits of the medical use of marijuana. 

The medical and scientific evi ljhce supporting the use of medical marijuana remains ' 

con~overs~al in the medi~1 com unity_ Not.all ~ealth car~ ~roviders believe that medical 

marIjuana IS safe or effective' an some providers feel that It IS a dangerous drug, 

, According to the Washington State law the benefits Qf medical mariju'1na may include 

treating nausea and vomiting from chemotherapy, AIDS wastingsyndror'ne, severe muscle 

, spasms from multiple sclerosis or other spasticity disorders, glaucom

,,' ... 

Nov. 26. ·2008 4:50PM CBR Medical Inc. No. 2428 P. 1113 

3'1'15 E. Mission Ave 


~o: -00( .J:lli:..dl£..£L\ D \ fR:.d(·; r fl'Om: C.' p K Vlf\e.~",. ,\,-__ 

. Fax: 3('~O ··5~o;~5:; . __ 

. ".~~~.I~~.~' .. _' __ , __ 

, Pages: f.,;,(, 

.--. ---'- ..-.,--..;..'._.._---- 

, ec~ .. ~~ ___._...__ 

1urgent 0 For R.eview [J Please Ccmmen~ [J Please Jleply 0 Please Recydo 

---_. ---- 

-Comn:"lsnts: 

, GBR Modical, Inc.· 3115 E. MtssionAve, Spok£me, Wa 9020 . 

Seattle Phone 206-774-6493 F.,x 206-4iB-6659 Spok.me Phone 509':242-8624 r=ax G09··340-2710 

TTi-Cities Phune H09-116-2267 Fax ti09-340-2710 VancoUver Phone 360.p3G-6464 rax 206-418-6659 

CONrIDENTIALlTYNOTICF.: ThIs communication is intended for the sale us~ of the individual snd 

entity to whom it is addressed, and may contain Itlformation that is prtvlleged .. or confidential and 

exempt from disGIClsurc under applicable law.' You are hereby notified \hat any dis.~einin£iti()n, 

distribLllion, or duplication of this comniuniV,lticn by someone other Ulan the intended addressoe or iis 

deRign;:iled agent isstrict!y prohibited: . ' 

All Information is protected Under U.S. Federal La.w 

PDU-6655-3 000479


From: 

Sent: 

To: 

Subject: 


Tuesday, December 09, 2008 9:28 AM 

Rud~ E. VonciUe (DOC) 

FW:~M Authorization Request 

FYI- 

This off(;mder's request has been denied. 



Karen Daniels;' Assistant Secretary 




(360) 725-8796 


From:. ' 

. Sent:' 

To: 

Subject: 

Hammond, G. steven (DOC) . 

Monday, December 08, 20084:38 PM . 

. ~M'AiJthoriZatiOn Request 

Not consistent with DOC policy 





POB 41123 

Tumwater, WA.98504-1123 

360-725-8700 

. 1: 

PDU-6655-3 000480

Jan. 4. 2009 12:39PM CBR Medical Inc. No. 2927 P. 1 

3'1111 1:::, Mi~tiinn Ave 

. fipoksnp.. WP. [JOO 

f 

[ijJl)£J41. 

cAI~s~~ 

lLJ~· 

CBR Medil.:;'tl, Inc. - ::111 ti E. Mff;~~ion/Wu, SpOI(kllln, Wa 9920 

:·;Ar:lttlr.: ['heme 20f:i ..(1t1·G4!·)3 ruxm'i-l!-'18-f'il'i:i9 f·'pni(anr.: rl10ns G09 ..:.',47.-B62'1 f""x ti09·,~r4(~:l(10 

Tli .. Ciup.s PI lone 509 416-2f'l'i I"7Clx 5(lSl-3'10 ..'t'lO VW)r,C)UVCI' l'I10ne 3GO,f';:lti-6~G1 1-3)( 20tJ,41!l-06GF) 

, CONrlD[l'-ITII\LlTY NCHICI:::: II,i5 GomlTlunientinn is interrlit.cl for the solo !.ISlA of tho individual and 

entiiy [0 whom 'it is

.' 

:r 

Jan. ~ 2009 12:39PM C B R Me d i cal Inc. 

No, 2927 p, 2 

Hello and good day. 

The following leHer is written' on hehal r () 

\\'''shl'ngt''n V'/w..;.. \oJ (.Jill""'- 1.1 t..,i n"'p""'''''''''n' .... "'":;a.i.~ili.,.. i..,.!. 1,I·C" .. vll~",~,l.:a 

..........·j;riTI" 

is an

Jan. 4. 2009 12:40PM 

DEC-30-2UU8 01:38 p~ 

CBRMedi.callnc. 

DOG GG lJU' ljl:.G 360 586 0252 

No. 2927 P. 3 

P. U 1 

STATIHlF Wi\SlnNCiTON 

DEPART,MENT OF"CORRECrYONS 

P.O. a, •.• 41126· ()/l'lTIpla. \V .. hlngwll'lk~'l4-1 126 

-......--......---=--~ to, 

........... - .......:"""""""":'---,,-..... 

COMf'''NY: 

FA)(NlJM8~: 

509~340-2710 

PHONE NUMBER: 

FACSIMILE TRANtUlflTTAL SH!:/i;T 

"'!"".... 

.=-".....!""! 

FROM: 

•• ,,,•.,..; 

= 

•• -"""""--~...-,,,,- 

Malisu McGhee 

MonJca Distefano 

.---------............----~---~...:...---~~ 

DATE: 

DECEMSER 30,2008 

TOTAl. NQ, OF f'AGES INCLUDING COVER; . 

3 

SENOSR'S PHONe NllMRER: 

360-n5.:e796 

--~---~--R-r;N.....;cE;.s FAX NUMBER: 

360-586-0252. 

~-===----~===== 

D IIROI:.N·j'· X FOR REVIEW. 0 PLeASe C(lMMEN1' 0 PLEAse RePLY D pl.MSe ReCYCLE 

-=="""",,,,,,,,,,==--,,,,,,,,===----.. • ....... ,-=="'"""-~====== 


Executive Sar..retarY 

36()'·725--8796. 

PDU-6655-3000483

Jan. 4. 2009 12:40PM CBR Medical Inc. 

No. 2927 P. 4 

DE(;-JU-,_UU~ 01: j~ PM Duu UIJ ~I:.P ~tU 380 586 0252 

p, lJ~ 

Rov·.26. 2008 4:52PM. COR Medical Inc. 

, No. 2428 P. 5/13 

to be fillet! out by flrescr/ber: 

. ,... 

- - -._1.- . 

- IOate Oftch -- IJibe Number '~J 

~_I"~ 

Dear Ptoscrlber, . 

By state &!mute the Wash!r_ ~tatc Deoartmcnt it CorrecUonll Is charQed with thei resoohliibnltJ/ /0 aut)arvil!c ijtlnw 

olfendors after1ht.'Y have been canviated IJf l'1·fpJony. The :aoova 11~ItICld patient is I:UtTenfly under supeNIsiol1 by the 

D~partrnent SUPt;(V4ttQIl ill de:;igqed to 1Tc,llp tho orfel1der avoid those environments or situations that lead 10 their crIminal 

·behaviot'. Often illicit dnJg ~ Is a contributing factor in an irldividual's Criminality. Acccrdingly it's usual that the court or 

the Department of Corrections will impose 3 condition of supetVislon that the offlmQ'lr rint Il50, or pO~ll ifficitdIiJO", 

1nc:ILlomg marijuana. This offender has claimed tila! they tlt~ve u c:nndlllon for which the medicinal U13e t1f manjllana has 

btlon rucommcnQ"ed. The b¢luw verllic!lOon is to determine the legitimacy of th~jr claim. Thank you in advance for ycur 

assistance. If yell have quostions please 1ee! free to pe!1!Orlally conlEcl the Medical DireGior of !hE! Department at (360) 

725.B7OO. ' 7. 

1. III Ihl$ proian! under )'Out CZII'1)'/ . . ., . . m,s tJ N/ 

2. Are you recQmm~ndinll medical milrljuana for his patient dura to a dlannL'Jllis of Arquitp.d 

Immuncdeficienay Syndrome (AIDS) 

U Va!! GfNo 

It Jt !Ile allswer toqlJE):;Uon 2 is .'Yes', ~oe$ he/she imve anorexilil e-'I'~f".1l'4Q I"l4 

b. If the answer to questlon 211 Is ·Yes·, does hclshe have weight loss [J.XeS--8-No NiH 

IN 

DYes ~ 

3. Are you recommending tn(il!!I~'11 JIlf;lTqU·.aIIi:1 for this peUI:II\ \Jus tel I1lU.1sea and.vomiting 

. t,!!lsurJ:.rll.!ti wlth-l;anCCl' chemotherapy . . 

s. . If the BnllWerto qucsU'on :3 is 'Yes', has Ule patient falfed to respond !Q conventional f.t' p No fo~ 

antiemetic; treatments . 'Ns "1ft 

b. If tho

Jan. 4. 2009· 12: 41 PM CBR Med i ca 1 Inc. 

DEU-ju-,uUtl U1; IJlJ I'M DU\i \i\i 'IJH 1:lt\i 360 586 0252 

Nov'. 26. '20~a 4,.·52PM. tiRO M J' I J 

I. ~ nplca nco 

No. 2927 p P: 5 

, Uj 

Medical Dflutter . 

Health SerViee!l .Divislon 

Washington State Departm~nl of Cortef.!!\Ona 

PO 8011411'.3 

Olympia. WA 98504-2113 

10 ""' filled ou~ by boe Physician: 

--.-.... ~.;. 

. I have reviCwoo Ihis vorifioatlon fo!I\'l ~t1 find 111m U:1a gf Il'Icdlr...r OICilijUt1l'1li Ill' this PClU~rlt 

(check:OIIr'!) I [1 ill Ul'Ts not .' , . .' . 

(,;01mJtont wiHI 00 a ComrnLll1Ity Corrections He


From: 

Sent: 

To: 

Subject: 

Distefano; Monica J. (DOC) 

Tuesday, December 09, 2008 9:28 AM 

Rud~E. Voncille(DOC) 

FW----.",M Authorization Request 

FYI- 

This offender's request has been·denied. 



Karen Daniels'; Assistant ·Secretary 

Community Corrections Division. 



(360) 725-8796 


From: 

Sent: 

To: 

Subject: 


Mond~y, December 08, 2008 4:38 PM 

'.1- ~~-.~.e 


Not consistent with DOC policy 





POB 41123 

Tumwater, iNA. 98504-1123 

360-725-8700 

J. 

1 

PDU-6655-3 000486





DeatMs_ 

. Your Medicinal Use of Marijuana request was received on December 23, 2008. Upon review by the 

Department of Corrections' Health Services physician, your request has been derued. 

You may appeal this decision by sending your written request within 15 business. days of this' letter, 


Karen Daniels,. Assistant Secretaly 



P.O. Box 41126 

Olympia, W~ 98504-1126 

, , 

, Your request must provide additional iriformation that was not, included with your original request. 

Appeals that do not contain new informa1;ion will be, denied. You will receive' a response to your 


KD:md 

cc: 'JeffFrice, Community Corrections Supervisor 

Neil Crannell, Community Corrections Officer 

Field File 



CBR Medical . 


Spo~ane, WA 99202 

, " Working Together for $AFE Cqmmunities" , 

~ recycled p:lpcr 

PDU-6655-3 000487


From: 

Sent: 

. To: 

Subject: 


Thu January 08, 2009 1 :23 PM 

(DOC); Dist~fano, Monica J. (DOC) 

DOC # provided· 

Ms. _ 

request for medical marijuana use does no~ meet medical neccessity criteria. 





POB 41123 

Tumwater, WA 98504::1123 

360~725~8700 

.1 

PDU-6655-3 000488

J 

1. 

I Fax 

caR Medica!, lilC 

3115 E. Mission Ave' 

Spokane, WA992D2 

cc: 

=~o 

PleasE! Comment Cl Plea~l~ M~ ~ ""'" "~ply r-I l..J "'1 or ease Rac:ycl0 

---"---~.-,--- ----. ,-----, 

OBR Medical, lric,· 3116 E, Mission Ave, Spokane, Wa 99202 

'.SG:attle Phone 206-774-6493 Fax: 206-418-6659 Spokane Phone 509-242.-8624 Fax 509-340-2710 

Trl-Clties Phone 509-416,,22ElT Fax {508-340-7'l0 Vancouver Phone 360 .. 635-6464 Fax 296-4113-6659 

CONFIDENTIALITY NOTICE: This communication 'is intended for the sale usa of the individual and 

elltity to whelm' it is addressE:d, and ·ma.y c::ontain information that It; privileged, or c!ollfldential and 

exempt from disclosure under iilPplicable law. You are hereby notified that &lny dissemination, 

distIibulioli, or dllplication of this communication by someqne other \han the intended addressee or its 

desi[:!nated agent Is strictly pl'ohibited" . ' 

All Information is Protectad Ul1derU,S, Fader~1 Law 

PDU-6655-3 000489

(i &1 

. OEPARTM"ri;;.toF·COruu:CTIONS 

. ()FF~NDER 1.0. DATA: 



. Dear Prescriber, 

By state statute the Washington State Department of Corrections is chargep with the responsibility to supervise some 

offenders after they have been convicted of a felony. The above named patlelit Is Gummtiy under supervision by the 



the Departrnentof Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, 

including marijUana. This offender has clairiwd that th.ey have a condition for which the medicinal use of marijuana has 

been recommended. The below verification is to determine the .Iegitimacy of their claim. Thank you in advance for your 

asststance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 

725-8700. . . . /" 

1. Is this pati~nt under your care CYes D No 


Immunodeficiency Syndrome (AlDS) 

3. 

a. If the answer to question 2 is ';YeS', does he/she have anorexia "tAb. 

lfthe answer to question 2a is "Yes·, does he/she have weight loss' N/!>r" 

Are you recommending medical marijuana for this patient due to nausea and vomItIng 

ass~ci~ted with cancer chemotherapy 

D.yes 

[;d1fo' 

~-LtN6 

Q-¥es---B'Nd 

DYes 

a. If the answer to question 3 is 'Yes", has the patient failed to respond to conventional Q.¥es---!.;}Ne-' 

antiemetic treatments III fA-- . . 

b. If the. answer to question 3a is ·Yes". .please describswhatthose treatments were (medication, dose, 

d~ration): . ;/! Pr . . '. 

c, What is the planned schedule of chemotherapy rJ / A- 

4. 

If yo.~ answered "No' to items 2 & 3 ~bove, what is th~ rea~on you are recommending medicinal use of 

manJuana . ~J~

License#: 


Medicar Director 

Health Services Dili'isi.on . 

Washington State Department of COllections 

PO Box 41123· 

Olympia, WA 98504-2113 

I have reviewed this verificatin f0r-~.1nd find that use of medical marijuana by, this p



PATIENT NAME: _~_ DATE OF BIRTH: ~ 

I, Antoine Johnson ,am a physician licensed in the state of Washington 

and I am treating the above patient for a tenllinal illness or. a debilitating condition .as d~fined by 

RCW 69.51 A.01 O. .' ,,-' .... '-~'- .. 

I have advised the above named patient about the potll1ti·a1'risks and enefits of the medical use 

of marijuana. 1.l18ve assessed the above named p..liliient's medical h' tory and medical condition. 

It is my medical opinion that the potential benefits of the medical u of marijuana may outweigh 

the health risks for this patient. .'." ,. . 

. f .. 

Physician Name: Dr, Antoine John's~1l . WA Lice'h~e Number: Mb00039048 

. ,/ 

.. , 

Physician SignatLlre: ___ '-:>/'>.i Date: 04/1312008 

------~----------~,~,~~ -----~~~~--~-- 

04/13/2009// .I.' 

... ; 

" 

Risl(s and benefits of medicai marijuana ,/. 

Undel'.washington law, the use of m ieal madjuana is now p~rmissible for some patients . 

with lermhialol' debilitating Illnesses. he law,{egulatlng this (RCW 69:51 A) allows physicians 

/ . 

to advise patients about the risks a benefifs of the medical use of marijuana. . 

The medical and scientific evi .nce s~Ip'f'1orting the use of ri1!Odicai marijuana remains 

contro\(ersial in the medica. I ~orr unity/'Not aUllaslth care providers believe that medical 

marijuana is safe or effective d so;:rie providers feel that it is a dangerous drug. 

According to the Washing n Mite law the benefits of medicsl marijuana may include 

treating nausea and vomitin . m chemotherapy, AIDS wasting syndrome, severe musc!e 

spasms from multiple ~clero IS or. other spasticity disorders, glaucoma, and some types of 

intra«table pain. . 

Some of the risks of medical marijl.lana may include possible long-term effects of the brain in 

. the areas of memory, coordination and cognition; impairment of the ability tb drive or operate 

heavy machinery; respiratory daiTl1'1ge; possible lung cancer; and physical or psychological 

dependence,' . . . 

This re~omme'ndation'expireJ~n: 

, 


As this patient's "60 day supply", as stip'ulated by RCW 69.S1A(2)(b), I re~ommend 24 ounces 

of dried, cured marijuana anti as many plants as the patient feels necessary to maintain this "60 

day supply", 

Rovisyu -, /07 

PDU-6655-3 000492

DOC request three complete - Cannabis Defense Coalition

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