New Jersey's Medical Aid in Dying for the Terminally Ill Act requires the attending clinician to document each step of a request on form MAID-7. It records the eligibility determination, the patient's oral and written requests, mental status, the dispensing provider and the medication prescribed. Clinicians meet it after prescribing, and the Office of the Chief State Medical Examiner uses it to follow up for the death certificate.
The attending physician or advanced practice nurse who determined the person was a qualified terminally ill patient completes and signs the five-page form. The consulting physician and any mental health professional complete their own compliance forms, which are attached.
Download the current version from the source each time; forms change without notice.
Attending Physician Compliance Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The form must be filed as soon as possible and no later than 30 days after the qualified terminally ill patient's death, under P.L.2019, c.59. It goes to the Office of the Chief State Medical Examiner with the patient's written request and the consulting and, if used, mental health compliance forms attached.
That they determined terminal illness, capability and voluntariness; required proof of New Jersey residency; informed the patient of diagnosis, prognosis, risks, probable result and alternatives such as hospice and palliative care; referred to a consulting physician; addressed mental health referral; advised against taking the medication in public; and met the record documentation requirements.