Fillable Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting (Death With Dignity)

Fill Online, Printable, Fillable, Blank Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting (Death With Dignity) Form

Use Fill to complete blank online DEATH WITH DIGNITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting (Death With Dignity)

On average this form takes 10 minutes to complete

The Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting (Death With Dignity) form is 2 pages long and contains:

  • 1 signature
  • 15 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Death With Dignity forms online.

BROWSE DEATH WITH DIGNITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Attending Physician Who Prescribes Medical Aid-in-Dying
Medication Reporting Form
Mail completed form to:
Colorado Department of Public Health and Environment
Attn: Kirk Bol, Vital Statistics Program
4300 Cherry Creek Drive South, Denver, CO 80246-1530
Items that must be submitted:
1. Completed and signed Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting Form
2. Copy of patient’s written request for aid-in-dying medication
3.Copyofconsultingphysician’swrittenconrmationofdiagnosis,prognosis,andmentalcapacitydetermination
4.Copyofmentalhealthprovider’swrittenconrmationofmentalcapacity(ifapplicable)
(Thisformmayberevisedperiodically.Toassurethatyouareusingthemostcurrentversion,pleasereferto:https://www.colorado.gov/cdphe)
Please print:
A Patient Information
Patient’s Last Name Patient’s First Name Middle Initial Date of Birth
Medical Diagnosis
B Prescribing Physician Information
Physician’s Last Name Physician’s First Name Middle Initial Telephone#
()
Mailing Address
City, State and Zip Code
C Actions Taken to Comply with the Law (indicate compliance by checking the appropriate boxes.)
1. First Oral Request
Thepatientmadeanoralrequestformedicalaid-in-dyingmedication. Date
2. Second Oral Request (must be made 15 days or more after the rst oral request)
Thepatientmadeasecondoralrequestformedicalaid-in-dyingmedication. Date
3. Written Request
Thepatientmadeawrittenrequestformedicalaid-in-dyingmedication
ThewrittenrequestcomplieswithSections25-48-104and25-48-112,C.R.S.
(Please attach a copy of the written request.)
Date
4. Physician Determinations
Determined that the patient:
Is suffering with a terminal illness;*
Has a prognosis of six months less;**
Is mentally capable of making and communicating an informed decision (If you obtained a written conrmation
of mental capacity from a licensed mental health provider to assist you in making this determination, please
attach a copy of the written conrmation.);
Isvoluntarilyrequestingmedicalaid-in-dyingmedicationthathasnotbeencoercedorundulyinuencedby
others;
Is at least 18 years old and a Colorado state resident;***
Hasbeennotiedoftherighttorecindarequestforaid-in-dyingmedicationatanytimeandinanymanner.
(continue to page 2 on reverse side)
revised 1/2018
Clear Form
5. Consulting Physician Information
Referredthepatienttoasecondphysicianformedicalconrmation(Pleaseattachacopyoftheconsulting
physician’swrittenconrmationofdiagnosis,prognosis,andmentalcapacitydetermination.)
Consulting Physician Last Name First Name
Middle Initial
Telephone#
()
Mailing Address
City, State and Zip Code
D Medication Prescribed and Final Attestation
1. Medical Aid-in-Dying Medication Prescribed
Medication Dose Date
2. Medical Aid-in-Dying Medication Dispensed
Dispensed medication directly to the patient. Date
Delivered a written prescription to a licensed pharmacist.
Notiedpharmacistthatthemedicationwasprescribedforthepurposeofmedicalaid
in dying pursuant to statute.
Date
Pharmacy Name Telephone#
()
City, State and Zip Code
3. Final Attestation
Tothebestofmyknowledge,alloftherequirementsoftheColoradoEnd-of-LifeOptionsActhavebeenmet.
Physician’s Signature Date
*PursuanttoSection25-48-102(16),C.R.S.,“Terminalillness”meansanincurableandirreversibleillnessthatwill,withinreasonablemedical
judgment, result in death.
**PursuanttoSection25-48-102(12),C.R.S.,“Prognosisofsixmonthsforless”meansaprognosisresultingfromaterminalillnessthattheillness
will,withinreasonablemedicaljudgment,resultindeathwithinsixmonthsandwhichhasbeenmedicallyconrmed.
***PursuanttoSection25-48-102(14),C.R.S.,residencycanonlybedocumentedwith:1)PossessionofaColoradodriver’slicenseoridentication
card;2)aColoradovoterregistrationcardorotherdocumentationshowingtheindividualisregisteredtovoteinColorado;3)evidencethatthe
individualownsorleasespropertyinColorado;or4)aColoradoincometaxreturnforthemostrecenttaxyear.Theprescribingphysicianis
requiredtoafrmColoradoresidency.
page 2
Attending physician who prescribes medical aid-in-dying medication reporting form (continued).
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Attending Physician Who Prescribes Medical Aid-in-Dying Medication Reporting (Death With Dignity)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document