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Forms for Patients and Providers

Patient Forms


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Instructions

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:

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:

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

All forms should be mailed to:

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