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Forms

Patient Forms

• Written Request for Medication to End My Life in a Humane and Dignified Manner form, DOH 422-063, (PDF, 42 KB)

Provider Forms

• Attending Physician's Compliance form, DOH 422-064 (PDF, 46 KB)
• Consulting Physician's Compliance form, DOH 422-065 (PDF, 35 KB)
• Psychiatric/Psychological Consultant's Compliance form, DOH 422-066 (PDF, 33 KB)
• Pharmacy Dispensing Record form, DOH 422-067 (PDF, 32 KB)
• Attending Physician's After Death Reporting form, DOH 422-068 (PDF, 117 KB)

To comply with the act, within thirty calendar days of writing a prescription for medication under this act, the attending physician shall send the following completed, signed, and dated forms:

• Written Request for Medication to End My Life in a Humane and Dignified Manner form, DOH 422-063, or in substantially the same form as described in the act;
• Attending Physician's Compliance form, DOH 422-064;
• Consulting Physician's Compliance form, DOH 422-065; and
• Psychiatric/Psychological Consultant's Compliance form, DOH 422-066, if an evaluation was performed.

Within thirty calendar days of a qualified patient's ingestion of a lethal dose of medication obtained under the act, or death from any other cause, whichever comes first, the attending physician shall complete and mail:

• Attending Physician's After Death Reporting form, DOH 422-068

To comply with the act, within thirty calendar days of dispensing medication, the dispensing health care provider shall file a copy of:

• Pharmacy Dispensing Record form, DOH 422-067

All forms should be mailed to:

State Registrar
Center for Health Statistics
P.O. Box 47856
Olympia, WA  98504-7856