Fillable Health Care Provider who Dispenses Medical Aid-in Dying (Death With Dignity)

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Health Care Provider who Dispenses Medical Aid-in Dying (Death With Dignity)

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Health Care Provider who Dispenses 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 Health Care Provider who Dispenses Medical Aid-in-dying Medication Reporting Form
(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
B Prescribing Physician Information
Physician’s Last Name Physician’s First Name Middle Initial Telephone #
( )
C Dispensing Health Care Provider Information
Provider’s Last Name Provider’s First Name Middle Initial Telephone #
( )
Mailing Address
City, State, Zip Code
D Aid-in-Dying Medication Dispensed
Medication Quantity Date Prescribed Date Dispensed
Dispensing Health Care Provider’s Signature Date
revised 1/2018
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Health Care Provider who Dispenses Medical Aid-in Dying (Death With Dignity)

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Completed 11 March 2021

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