Edited by Foxit Reader
JIMENEZ- EWA BEACH Copyright(C) by Foxit Software MEDICAL FOUNDATION CLINIC
Company,2005-2007
For Evaluation Only.
American Board of Family Practice Fellow, American Board of Family Physicians 91-896 Makule Rd., Suite 102 Ewa Beach HI Phone: (808)689-4414 eFax: (808)404-0019 Questions: 1-800-215-HERB
REQUEST FOR RELEASE OF MEDICAL RECORDS
7/11/08 DATE: _____________
Fletcher Gary Patients LAST NAME: _______________FIRST NAME: ________________
11/8/1955 N3706281 DOB: __________Driver's Lic./ID/Passport or SS#: _________________
SIGNATURE: __________________________________________________
I HEREBY AUTHORIZE:
Dr. Alfonso Jimenez MMOC TO: _________________________________________________________________
Box 999 ADDRESS: ___________________________________________________________
__________________________________________________________
Laguna Beach CA 92652-0999 CITY: ___________________ STATE: _____________ ZIP CODE: _____________
PHONE:_____________________ FAX:____________________________________ 1-888-215-4372 808-440-0019 To release information to Dr. Alfonso Jimenez: (circle mailing address where records will be sent) San Diego Patients: Dr. Alfonso Jimenez Orange County Patients: Dr. Alfonso Jimenez
MMSD
MMOC
420 K. St #13
Box 999
San Diego, CA 92101
Laguna Beach, CA 92652-0999
Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2007 For Evaluation Only.
Hawaii Patients: Dr. Alfonso Jimenez Los Angeles/Santa Barbara Patients: Dr. Alfonso Jimenez
MMHI
MMLA/MMSB
91-896 Makule Road
9663 Santa Monica Blvd.
Suite 102
Box 999
Ewa Beach, HI 96706
Beverly Hills, CA 90210
eFAX: 808.440-0019 (only use fax for up to 6 pages of medical records or less-we require only a "Summary of your Medial Records")
I request that copies of my medical records including, but not limited to, the following items be sent: __ Problem list/ Medication list (Summary only) __Other_________________________ Pepcid 40mg
Note: we do not need your entire medial records, just a summary or Medical/Mental health Problem list and Medication list (this is usually one to 3 pages page)
My medical/mental records are being requested for the purpose of validating this patient's qualifying diagnosis (es) to begin or continue the use of Medical Marijuana (Cannabis). This authorization is valid for six months from the date of signing unless revoked in writing by the undersigned prior to six months.This undersigned may revoke this by submitting a letter to JIMENEZEWA BEACH MEDICAL FOUNDATION CLINIC 91-896 Makule Rd, Ste#102 Ewa Beach, HI 96706 or faxing to 808.689.7115. I understand that the revocation will not apply to any action to in reliance on this authorization.
Please provide Dr. Jimenez records now, or within six months, from one or all the following provider (s): Primary Care Provider (PCP), Orthopedist/ Physical Therapist/Psychiatrist/ Occupational Provider, Neurologist/ Neurosurgeon, Chronic Pain Specialist, Hematologist/ Oncologist, Aids Clinic, Ophthalmologist/ Optometrist, Psychiatrist/ Psychologist, Doctor of Chiropractics, Doctor of Naturopathy, Acupuncturist or other professional you deem as your primary care provider. It is important to understand that Dr. Jimenez acts as a Consultant (Qualified Medical Marijuana Examiner) only - he is not your primary care provider. Proof or validation of your medical or psychological diagnosis(es) is required from a licensed provider. If you have not provided records during this visit, Dr. Jimenez will ask for physical proof or validation of your qualifying diagnosis(es) prior to your six month follow up, i.e., Letter head, Rx form, or other properly documented medical or psychological or legal report. After receiving your medical records and re-evaluation you will be renewed or approved for the medicinal use of cannabis for one year. If you haven't seen a provider related to the above-referenced diagnosis (es), it was because you informed Dr. Jimenez that you don't have medical insurance or adequate medical insurance, or because of financial difficulties, or because of past medical or psychological dissatisfaction from the AMA or AOA. But you have agreed to see a licensed provider per the request of Dr. Jimenez prior to your six month visit.
SPECIAL NOTE This communication is intended solely for the individual or the entity of which it is addressed and may contain information that is privileged, confidential from disclosure. If the reader of this communication is not the intended recipient, you are hereby notified that any distribution, or copying of the communication is strictly PROHIBITED. If you have received this communication in error, please verify us immediately at the above telephone number provided. Return the original message to us at the following address via the U.S. postal service. Your cooperation is greatly appreciated. Thank you.
Dr. Jimenez can: Discuss, fully and candidly, the risks and benefits of medical marijuana with patients. Recommend (or Approve, Endorse, Suggest, or Advise, etc.), in accordance with their medical judgment, marijuana for patient use. Record in his patients' charts discussions about and recommendations of medical marijuana. Sign a government form or otherwise inform state or local officials that he has recommended medical marijuana for particular patients. Testify in court or through written declaration about recommending medical marijuana for a certain patient. Educate himself about the medical benefits of marijuana, its various clinical applications, and different routes of ingestion. Dr. Jimenez cannot prescribe medical marijuana. This includes writing a recommendation on an Rx form. Dr. Jimenez cannot assist patients in obtaining marijuana. Dr. Jimenez cannot cultivate or possess marijuana for patient use. Dr. Jimenez cannot physically assist patients in using marijuana. Dr. Jimenez will not recommend marijuana without a justifiable medical cause. This website does not endorse or promote the sale of marijuana. This includes any link to a site that transports, imports into this state, sells, furnishes, administers, gives away, or offers to transport, import into this state, sell, furnish, administer, give away, or attempts to import into this state or transport any marijuana. It is a felony to sell, transport, or distribute any amount of marijuana in the State of California or Hawaii. Any attempt to purchase marijuana illegally maybe punished by imprisonment in the state or federal prison or a fine. Any person who uses Prop 215 as a 'smoke screen' with intent to sell marijuana is considered a felony, and anyone convicted of such crime will be harshly punished. Respect Prop 215! CONANT v WALTERS
DISCLAIMER