California's End of Life Option Act requires the attending physician to file this three-page checklist after prescribing an aid-in-dying drug. It records the patient and consulting physician, the terminal disease, the eligibility determinations, required counseling, the dates of both oral requests and the written request, the patient's mental status, and the aid-in-dying and antiemetic drugs prescribed with dosage.
The attending physician completes and signs the whole form, including the consulting physician's name and license number and, if a referral was made, the mental health specialist's details. The consulting physician files a separate compliance form.
Download the current version from the source each time; forms change without notice.
Attending Physician's Checklist & Compliance Form
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.
Within 30 calendar days of writing the aid-in-dying prescription. The attending physician sends it with a copy of the patient's written request and the Consulting Physician's Compliance Form. CDPH accepts the forms through its EOLA Online Forms Portal, where they can be signed electronically, or by mail or fax.
The attending physician checks that the patient was counseled on keeping the drug in a safe and secure place, having another person present at ingestion, not taking it in public, notifying next of kin, and participating in hospice or palliative care, and that feasible alternatives such as comfort care and pain control were discussed.
No. SB 403, signed October 3, 2025, removed the Act's expiration date so it continues indefinitely. Attending physicians still file the checklist, consulting physician form and follow-up form with CDPH, which launched a redesigned EOLA online application on October 8, 2025.