CONSULTING PHYSICIAN’S COMPLIANCE FORM
ORS 127.800 - ORS 127.897
Deliver this form to the attending/prescribing physician who will mail it to:
Oregon State Public Health Division, Center for Health Statistics,
P.O. Box 14050, Portland, OR 97293-0050
PLEASEPRINT
PATIENT’S NAME (LAST, FIRST, M.I.)
B REFERRING/PRESCRIBING PHYSICIAN
REFERRING/PRESCRIBING PHYSICIAN’S NAME (LAST, FIRST, M.I.)
2. Check boxes for compliance. (Both the attending and consulting physicians must make these determinations.)
1. Determination that the patient has a terminal disease.
2
. D
etermination the patient has six months or less to live.
3
. D
etermination that patient is capable.**
4
. D
etermination that patient is acting voluntarily.
5.
Determination
that patient has made his/her decision after being fully informed of:
a
)
His or her medical diagnosis; and
b) His or her prognosis; and
c
) T
he potential risks associated with taking the medication to be prescribed; and
d) The potential result of taking the medication to be prescribed; and
e
) T
he feasible alternatives, including, but not limited to, comfort care, hospice care and pain control.
Comment
s:
D PATIENT’S MENTAL STATUS
Check one of the following (required):
I have determined that the patient is not suffering from a psychiatric or psychological disorder, or depression,
causing impaired judgment, in conformance with ORS 127.825.
I have referred the patient to the provider listed below for evaluation and consulting for a possible psychiatric
or psychological disorder, or depression causing impaired judgment.
PSYCHIATRIC CONSULTANT’S NAME
E CONSULTANT’S INFORMATION
** “Capable” means that in the opinion of a court or in the opinion of the patient’s attending physician or consulting physician, a patient
has the ability to make and communicate health care decisions to health care providers, including communication through
persons familiar with the patient’s manner of communicating, if those persons are available.
Note: This form is revised periodically. To assure that you are using the most current version, please refer to:
http://www.healthoregon.org/dwd
Rev. 5/18
