The last of Hawaii's six Our Care, Our Choice Act forms closes out a medical aid-in-dying case. The attending provider reports the date of death and underlying illness, whether the patient died from ingesting the medication, any complications or barriers, and whether the patient was enrolled in hospice. The patient's Final Attestation Form can be attached.
The attending provider, a Hawaii-licensed physician or APRN qualified to make the diagnosis and prognosis, completes and signs the whole form.
Download the current version from the source each time; forms change without notice.
Attending Provider's Follow-Up Form
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The attending provider must complete it within 30 calendar days after being notified of the qualified patient's death, whether from use of the prescribed medication or any other cause, and mail a copy to the Department of Health. Patient information must not be faxed or emailed.
Yes. The attending provider may be a physician or an APRN licensed in Hawaii who is qualified by specialty or experience to make a professional diagnosis and prognosis for the patient's illness. The form asks the provider to check APRN or physician.