OPPPD/OUR CARE OUR CHOICE ACT 1 Attending Physician Follow-Up Form
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 ___
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.