Try for free

Maine Attending Physician End-of-Life Reporting Form

Maine physicians who prescribe medication under the Death with Dignity Act, 22 M.R.S. chapter 418, use this three-page report to document each step the law requires. It records the patient's oral and written requests, the physician's determinations on age, terminal disease, competence, voluntariness and residency, the informed-decision discussion, and the medication prescribed and dispensed. A copy goes to the State Registrar.

Who completes it

The attending physician, a Maine-licensed MD or DO, completes and signs Sections A to E; DHHS notes the Act does not extend to nurse practitioners or physician assistants. The consulting physician records their confirmation on the separate Consulting Physician End-of-Life Care form.

Submitting and payment

How to submit it
Keep the original in the patient's medical record and send a copy, with a copy of the prescription, to the State Registrar, Office of Data, Research, and Vital Statistics, within 30 days of writing the prescription.

Good to know

  • The written and second oral requests must come at least 15 days after the first oral request, and the prescription at least 48 hours after the written request, unless waived under 22 MRSA section 2140(14)(h).
  • Section C4 checks include referral to a consulting physician, a private conversation to rule out coercion, ruling out a psychiatric disorder or depression impairing judgment, and confirming an informed decision just before prescribing.
  • Section E asks the patient's principal medical coverage. Comments that run past the space go on an attached page labeled with the item, such as C3.
  • The current version is revised 09/2025; an older two-page file is still online. If an interpreter reads the request to the patient, the Interpreter Attachment Form also goes in the record.

Get the official form

Download the current version from the source each time; forms change without notice.

Attending Physician End-of-Life Reporting Form

Official pagePDF

Fill it with Vero

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.

See how Vero Documents works

How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When is the Maine attending physician reporting form due?

A copy is due to the State Registrar, Office of Data, Research, and Vital Statistics, within 30 days of writing the prescription, along with a copy of the prescription. The original stays in the patient's medical record. The End-of-Life Closure Form follows later, after the patient's death or 6 months after the prescription.

Who can be the attending physician under Maine's Death with Dignity Act?

Any physician licensed to practice medicine in Maine, meaning MDs and DOs. Maine DHHS states that the Act does not extend to other prescribers such as advanced practice registered nurses and physician assistants. Participation is voluntary for every health care professional, and a physician who declines transfers relevant records if the patient asks.

How does the physician confirm the patient is a Maine resident?

The form asks the physician to request that the patient demonstrate Maine residency and to check that they are satisfied. DHHS lists factors such as a Maine driver's license, Maine voter registration, leasing or owning property in Maine, or filing a Maine tax return for the most recent tax year.