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NOTICE: As of June 10, 2010, this form must be printed on "tamper-resistant paper" that includes one or more of the following industry-recognized features: (a) one or more features designed to prevent copying of the paper; or (b) one or more features designed to prevent the erasure or modification of information onthe paper; or (c) one or more features designed to prevent the use of counterfeit valid documentation. RCW 69.51A.010((5) ________________________________________________________________________________________________________________________________________________________________________________________
Documentation of Health Care Professional’s Authorization To Engage in the Medical Use of Marijuana in Washington State Patient Name ____________________________________________________________________ Date of Birth______________ Patient's Phone No.____________________________________ I am a health care professional licensed in the State of Washington under RCW 18.71 (physician); RCW 18.71A (physician assistant); RCW 18.57 (osteopathic physician); RCW 18.57A (osteopathic physician’s assistant); RCW 18.36A (naturopath); or RCW 18.79 (advanced registered nurse practitioner). I have diagnosed the above named patient as having a terminal or debilitating medical condition as defined in RCW 69.51A.010(6). 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 patient's medical history and medical condition. It is my professional, medical opinion that this patient may benefit from the medical use of marijuana. Signature of Health Care Professional ____________________________________________________________ Date _________ Printed Name of Health Care Professional ___________________________________________________________________ Health Care Professional's Phone No. _____________________________________ Washington Department of Health Credential Number _________________________ Risks and benefits of medical use of marijuana Under Washington state law, the medical use of marijuana is permissible for some patients with terminal or debilitating medical conditions. The law regulating this (RCW 69.51A) requires health care professionals to advise patients about the risks and benefits of the medical use of marijuana before authorizing them to engage in the medical use of marijuana. The medical and scientific evidence supporting the medical use of marijuana remains controversial in the medical community. Not all health care providers believe that marijuana is safe or effective for medical use, and some providers feel that it is a dangerous drug. According to the Washington state law, the medical use of marijuana may benefit patients diagnosed with the following 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; Crohn's disease; hepatitis C with debilitating nausea or intractable pain; or diseases, including anorexia, which result in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, or spasticity. Some of the risks of medical use of 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; and physical or psychological dependence. Smoking marijuana may cause respiratory damage and possibly lung cancer. Under Washington state law, the medical use of marijuana is permissible for some patients with terminal or debilitating medical conditions. The law regulating this (RCW 69.51A) requires health care professionals to advise patients about the risks and benefits of the medical use of marijuana before authorizing them to engage in the medical use of marijuana. The medical and scientific evidence supporting the medical use of marijuana remains controversial in the medical community. Not all health care providers believe that marijuana is safe or effective for medical use, and some providers feel that it is a dangerous drug. According to the Washington state law, the medical use of marijuana may benefit patients diagnosed with the following 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; Crohn's disease; hepatitis C with debilitating nausea or intractable pain; or diseases, including anorexia, which result in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, or spasticity. Some of the risks of medical use of 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; and physical or psychological dependence. Smoking marijuana may cause respiratory damage and possibly lung cancer. Text on this
form provided by the Washington State Medical Association. |
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