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Forms Received by the Washington Department of Health

DOH Publication Number	Form Name	2009	2010	2011
422-063	Written Request for Medication to End My Life in a Humane and Dignified Manner form	64	95	103
422-064	Attending Physician's Compliance form	65	100	109
422-065	Consulting Physician's Compliance form	67	103	108
422-066	Psychiatric/Psychological Consultant's Compliance form	4	2	8
422-067	Pharmacy Dispensing Record form	63	86	107
422-068	Attending Physician's After Death Reporting form	42	75	121

Initiative Measure 1000- Death with Dignity Act (211KB PDF)

Chapter 70.245 RCW

Chapter 246.978 WAC

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Last Update: January 31, 2012
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