Fillable ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN) (Death With Dignity)

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ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN) (Death With Dignity)

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  • 29 check-boxes
  • 35 other fields

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For Provider/Health Care Organization Use:
Medical Record #: _____________________
Or Patient Name: ______________________
1 Attending Physician Reporting Form
OPPPD/OUR CARE OUR CHOICE ACT
(eff. 1/1/19)
ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN)
Instructions:
The Our Care, Our Choice Act requires the Attending Physician to complete this reporting form
within 30 calendar days of the prescription date. Please attach all copies of supporting documentation as
indicated at bottom and mail to the Hawai`i Department of Health, Office of Planning, Policy, and Program
Development, Attn: OCOC/CONFIDENTIAL, 1250 Punchbowl St., Rm. 120, Honolulu, HI 96813. For inquiries
on this form, you may contact the Department at (808) 586-4188. Please do not fax or email any patient
information, completed forms and supporting documents to DOH.
A. PATIENT INFORMATION
PATIENT NAME (LAST, FIRST, M.I.)
DATE OF BIRTH
MEDICAL DIAGNOSIS AND PROGNOSIS
PATIENT ENROLLED IN HOSPICE: ____ YES ____ NO (Please recommend patient to enroll in
hospice if not enrolled.)
Check here if recommended: _______
B. ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN NAME (LAST, FIRST, M.I.)
PHONE NUMBER
MAILING ADDRESS
CITY, STATE AND ZIP CODE
C. REQUESTS FOR MEDICATION
DATE:
Recommended and Optional Actions (check all applicable boxes below):
I informed the patient and provided the following forms.
___ Patient’s Written Request Form (includes Declaration of Witnesses and Written Consent)
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For Provider/Health Care Organization Use:
Medical Record #: _____________________
Or Patient Name: ______________________
ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN)
2 Attending Physician Reporting Form
OPPPD/OUR CARE OUR CHOICE ACT
(eff. 1/1/19)
___ Final Attestation Form (optional)
___ Consulting Physician’s Confirmation and Verification Form. For example, if the patient scheduled or
has determined to meet with a consulting physician, acquire the consulting physician’s name and phone
number from the patient and make the referral. (optional)
___ Counselor’s Statement of Determination Form. For example, if the patient scheduled
or has determined
to meet with a counselor (e.g. psychiatrist, psychologist, or licensed clinical social worker) for the purposes
of expediting this process, acquire the counseling provider’s name and phone number from the patient and
make the referral. (optional)
___ I informed the patient that not less than 20 days must pass between the date of the first oral request and
second oral request.
less than 20 days from the date of the first oral request.
Initial below:
___ I offered the patient the opportunity to rescind the request and
informed the patient of his or her rights to rescind the request at any time.
___ (If applicable,) I provided the Final Attestation Form at the time of the
patient’s second oral request.
DATE:
patient’s completed written request)
DATE OF RECEIPT:
D. ACTIONS TAKEN TO COMPLY WITH LAW
Check all the following to indicate compliance:
___ 1. I determined that the patient has a terminal disease, is capable of medical decision-
making and has made the request for the prescription voluntarily.
___ 2. I determined that the patient is a Hawai`i resident (e.g. Hawai`i driver’s license,
registration to vote, recent tax returns).
___ 3. I informed the patient of the following:
___ Patient’s medical diagnosis;
For Provider/Health Care Organization Use:
Medical Record #: _____________________
Or Patient Name: ______________________
ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN)
3 Attending Physician Reporting Form
OPPPD/OUR CARE OUR CHOICE ACT
(eff. 1/1/19)
___ Patient’s prognosis;
___ Potential risks associated with taking the medication to be prescribed;
___ Probable result of taking the medication to be prescribed;
___ Possibility that the individual may choose not to obtain the medication or may obtain the
medication but may decide not to use it; and
___ Feasible alternatives or additional treatment opportunities including but not
limited to comfort care, hospice care, pain control.
___ 4. I recommended that the patient notify next of kin.
___ 5. I counseled the patient about the importance of having another person present
when the qualified patient self-administers the medication and of not self-administering
the prescription in a public place.
___ 6. I informed the patient of his or her right to rescind the request at any time
and in any manner, and offered the patient (or qualified patient) an opportunity to rescind the
request at the time of the patient’s (or qualified patient’s) second oral request made.
E. REFERRAL TO CONSULTING PHYSICIAN
I provided the Consulting Physician Confirmation and
Verification
Form to the following (check all applicable):
___ Patient
___ Consulting Physician
Note: Attach Copy of Completed Consulting Physician’s
Confirmation and Verification Form
Date of Referral:
Consulting Physician Name:
Consulting Physician’s Phone Number:
F. REFERRAL TO COUNSELING PROVIDER (e.g. Psychiatrist, Psychologist or Licensed Clinical Social
Worker
I provided the Counseling Provider Confirmation and
Verification Form to the following (check all applicable):
___ Patient
___ Counseling Provider
Note: Attach Copy of Completed Counselor’s State of
Determination Form
Date of Referral:
Counseling Provider Name:
Counseling Provider Phone Number:
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
(eff. 1/1/19)
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.
Date of Prescription:
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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ATTENDING PHYSICIAN REPORTING FORM (MAIL-IN) (Death With Dignity)

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Completed 11 March 2021

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