Fillable CONSULTING PHYSICIAN CONFIRMATION AND VERIFICATION FORM (Death With Dignity)

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CONSULTING PHYSICIAN CONFIRMATION AND VERIFICATION FORM (Death With Dignity)

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The CONSULTING PHYSICIAN CONFIRMATION AND VERIFICATION FORM (Death With Dignity) form is 2 pages long and contains:

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  • 4 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

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CONSULTING PHYSICIAN
CONFIRMATION AND VERIFICATION FORM
OPPPD/OUR CARE OUR CHOICE ACT 1 Consulting Physician Form
(eff. 1/1/19)
Instructions: Please provide this form to the Consulting Physician to complete and return to the
Attending Physician. A Consulting Physician is a Hawai`i licensed physician who is qualified
by specialty or experience to make a professional diagnosis and prognosis regarding the patient’s
illness. (Optional: The Consulting Physician may conduct the examination via telehealth.)
A. Patient Information
1. Full Name (Last, First, M.I.): ______________________________________
2. Date of Birth: __________________
3. Date of Examination: _______________________
4. Medical Diagnosis:
5. Prognosis:
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CONSULTING PHYSICIAN
CONFIRMATION AND VERIFICATION FORM
OPPPD/OUR CARE OUR CHOICE ACT 2 Consulting Physician Form
(eff. 1/1/19)
B. Attending Physician’s Information
1. Full Name (Last, First, M.I.): ______________________________________________
2. Address: ______________________________________________________________
________________________________________________________________________
3. Phone Number: _________________________________________________________
C. Consulting Physician’s Information
1. Full Name (Last, First, M.I.): ______________________________________________
2. Address: ______________________________________________________________
________________________________________________________________________
3. Phone Number: ________________________________________________________
4. Email (if available): _____________________________________________________
D. Confirmation and Verification Information
I attest that I am a licensed physician pursuant to Hawai`i Revised Statutes Chapter 453
and confirmed and verified all of the following requirements. (Check box)
___ I examined the patient and patient’s relevant medical records.
___ The attending physician’s diagnosis that the patient is suffering from a terminal illness.
___ The attending physician’s prognosis that the patient has 6 months or less to live.
___ The patient is capable (e.g. has the capacity), acting voluntarily, and has made an informed
decision.
Consulting Physician’s Full Name (Print): ___________________________________________
Consulting Physician’s Signature: __________________________ Date: ________________
PLEASE RETURN COMPLETED FORM TO THE ATTENDING PHYSICIAN
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CONSULTING PHYSICIAN CONFIRMATION AND VERIFICATION FORM (Death With Dignity)

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Completed 11 March 2021

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