For Provider/Health Care Organization Use:
Medical Record #: _____________________
Or Patient Name: ______________________
ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN)
4 Attending Physician Reporting Form OPPPD/OUR CARE OUR CHOICE ACT
G. WRITING THE PRESCRIPTION
Waiting Period Requirements (initial below; both conditions
must be met):
___ Not less than 48 hours have passed between the DATE
OF RECEIPT OF THE QUALIFIED PATIENT’S
WRITTEN REQUEST and PRESCRIPTION DATE; and
___ Not less than 20 days have passed between the FIRST
ORAL REQUEST and PRESCRIPTION DATE
Name of Medication Prescribed (indicate here):
Check all applicable below:
___ Immediately prior to writing the prescription, I verified
that the patient is making an informed decision (required).
___ I dispensed medications directly; or
___ I contacted the pharmacist of the qualified patient’s choice
and informed the pharmacist of the prescription; and
___ I transmitted the written prescription personally, by mail or
electronically to the pharmacist.
___ I provided the qualified patient the Final Attestation Form
and advised qualified patient to complete the form 48 hours
prior to self-ingesting the prescribed medication. Recommend
that qualified patient keep a copy and designate an individual to
return the original to the attending physician.
H. ATTENDING PHYSICIAN’S STATEMENT
By signing below, I attest that I am a licensed physician pursuant to Hawai`i Revised Statutes
Chapter 453 and that all requirements of the Our Care, Our Choice Act have been met and steps
taken to carry out the request, including identification of the medication prescribed.
Attending Physician’s Full Name (Print): _____________________________________
Attending Physician’s Signature: ____________________________________________
Date of Signature: ___________________________________
Required Attachments: 1) Patient’s Written Request; 2) Consulting Physician’s Confirmation and
Verification Form; and 3) Counseling Provider’s Statement of Determination Form.
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