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PHYSICIAN FOLLOW-UP FORM (MAIL-IN) ATTENDING (Death With Dignity)

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OPPPD/OUR CARE OUR CHOICE ACT 1 Attending Physician Follow-Up Form
(eff. 1/1/19)
ATTENDING
PHYSICIAN FOLLOW-UP FORM (MAIL-IN)
Instructions: Within thirty (30)
calendar days, following notification of the qualified patient’s
death from use of a prescribed medication, or any other cause, please complete this form and
mail a copy to the Hawai`i Department of Health, Office of Planning, Policy and Program
Development, ATTN: OCOCA/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 or related documents to DOH.
All information is kept strictly confidential.
1. Patient’s Full Name (Print): _______________________________________________
2. Date of Patient’s Death: ____________________________________________
3. Attending (Prescribing) Physician’s Full Name (Print):
_________________________________________________________________________
4. Attending Physician’s Phone Number: __________________________________
1. Did the patient die from ingesting the medical aid-in-dying medication?
Yes ___ No ___
Unknown ___
2. Patient’s underlying illness: ________________________________________________
_________________________________________________________________________
3. Was the patient enrolled in hospice at the time of death? Yes ___ No ___ Unknown ___
4. What type(s) of health care insurance coverage did the patient have?
Check all that apply:
___ Medicare ___ Private Insurance (e.g. Kaiser, HMSA, or other)
___ Hawai`i Quest/Medicaid ___ No Insurance
___ Military/TRICARE ___ Don’t know type; had insurance.
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ATTENDING PHYSICIAN FOLLOW-UP FORM (MAIL-IN)
OPPPD/OUR CARE OUR CHOICE ACT 2 Attending Physician Follow-Up Form
(eff. 1/1/19)
___ V.A. ___ Unknown
___ Other: ________________________________ (indicate other type of insurance)
5. Were there any complications or barriers? Please indicate below and/or provide comments.
____ Yes _____ No
6. If the patient died from self-administering an aid-in-dying medication, please provide the
following information if known.
Education Level
Race/Ethnicity
Sex
___ High School Diploma
___ Some College, No Degree
___ Associate's Degree
___ Bachelor’s Degree
___ Master’s Degree
___ Doctoral Degree
___ White
___ Asian
___ Native Hawaiian
___ Pacific Islander
___ African American
___ Hispanic/Latino
___ Male
___ Female
Statement by the Attending Physician: By signing below, I attest that I am a licensed
physician pursuant to Hawai`i Revised Statutes Chapter 453 and acknowledge all requirements
under the Our Care, Our Choice Act have been met.
Attending Physician’s Full Name (Print): ___________________________________
Attending Physician’s Signature: ___________________________________________
Date: ___________________________
PLEASE ATTACH A COPY OF THE FINAL ATTESTATION IF AVAILABLE.
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PHYSICIAN FOLLOW-UP FORM (MAIL-IN) ATTENDING (Death With Dignity)

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Completed 11 March 2021

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