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California EOLA Attending Physician's Follow-up Form

The attending physician closes a California End of Life Option Act case with this four-page form after the patient dies, whether from the aid-in-dying drug or any other cause. If death followed ingestion, Parts A and B record who was present, where and when the drug was taken, time to unconsciousness and death, complications, hospice status, coverage and the patient's concerns.

Who completes it

The attending physician signs the form whether or not present at death. If another licensed health care provider was present instead, that provider completes and signs Part A and the attending physician completes Part B; if no one was present, Part A may be left blank.

Submitting and payment

How to submit it
Send it to CDPH within 30 calendar days of the patient's death, through the EOLA Online Forms Portal, by mail or by fax.

Good to know

  • If the patient died of the underlying illness or another cause, such as terminal sedation or stopping eating and drinking, the physician checks that box, signs, and skips the rest.
  • Part A asks about complications such as vomiting or regaining consciousness, whether emergency medical services were called, and where the drug was taken, from a private home to inpatient hospice.
  • Part B records the prescription date, hospice status at the first request, coverage such as Medicare, Medi-Cal, Covered California or VA, and concerns such as loss of autonomy, dignity or uncontrolled pain.
  • CDPH accepts the form only if the attending physician signs it, and the form states that all information is kept strictly confidential.

Get the official form

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

Attending Physician's Follow-up Form

Official pagePDF

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.

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Frequently asked questions

When is the California EOLA follow-up form due?

The form says within 30 calendar days of the patient's death, whether from ingesting the aid-in-dying drug or from any other cause. CDPH's submission instructions phrase it as 30 days from ingestion or death from another cause, whichever comes first. It can be filed through the online portal, by mail or by fax.

Is the follow-up form needed if the patient never took the drug?

Yes. If the patient died from the underlying illness, the attending physician checks that box and signs, with no need to complete the rest. For another cause, such as terminal sedation or ceasing to eat or drink, the physician describes the circumstances and signs.

Who completes Part A if the attending physician was not present at death?

If another licensed health care provider was present, that provider completes and signs Part A, and the attending physician completes and signs Part B. If neither was present, Part A may be left blank. If the attending physician was present, they complete and sign both parts.