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Colorado MAID Attending/Prescribing Provider Form

Colorado's End-of-Life Options Act requires the provider who prescribes medical aid-in-dying medication to report to CDPHE's Vital Statistics Program. This two-page form documents the patient's two oral requests and written request, the prescriber's eligibility determinations, the consulting provider referral, the medication and dose prescribed, how it was dispensed, and a final attestation that the Act's requirements were met.

Who completes it

The attending or prescribing provider, a physician or APRN, completes and signs the whole form, including patient details and diagnosis, consulting provider details and pharmacy information.

Submitting and payment

How to submit it
Mail it to the CDPHE Vital Statistics Program or send it through the state's secure email portal, with copies of the patient's written request, the consulting provider's written confirmation and any mental health provider's confirmation of capacity.

Good to know

  • The second oral request must come at least 7 days after the first, unless the attending provider determines the patient will die within 48 hours of the initial request.
  • Determinations to check: terminal illness, prognosis of six months or less, mental capability, a voluntary request free of coercion, age 18 or older, Colorado residency, and notice of the right to rescind.
  • Residency can be shown only by a Colorado driver's license or ID, voter registration, owned or leased Colorado property, or the latest Colorado income tax return, and the prescriber must affirm it.
  • Section D records whether the provider dispensed directly or gave a prescription to a pharmacist and told them it was for aid in dying. The form is revised 10/2024.

Get the official form

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

Attending/prescribing provider 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.

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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

What must be attached to Colorado's attending provider MAID report?

A copy of the patient's written request for aid-in-dying medication, a copy of the consulting provider's written confirmation of diagnosis, prognosis and mental capacity, and, if one was obtained, a copy of the licensed mental health provider's written confirmation of mental capacity.

Does Colorado require a separate consulting physician form?

No. CDPHE lists only two required reporting forms, the attending or prescribing provider form and the medication dispensing form. The consulting provider's written confirmation is attached to the attending report, and the patient's written request must substantially conform to the statutory form in C.R.S. 25-48-112.

Is the information on Colorado's MAID report public?

No. CDPHE keeps it confidential and will not confirm case by case whether a person was prescribed aid-in-dying medication or whether a provider prescribed or dispensed it. The data, with death certificates, feed an annual statistical report of aggregate figures.