Hawaii attending providers file this four-page report when they prescribe medical aid-in-dying medication under the Our Care, Our Choice Act (HRS Chapter 327L). It records patient demographics and insurance, diagnosis and hospice status, the oral and written requests, compliance steps, referrals to the consulting and counseling providers, and the medication prescribed. Three companion forms are attached.
The attending provider, a Hawaii-licensed physician or APRN, completes and signs the whole form. The consulting provider, counseling provider and patient complete the attached forms.
Download the current version from the source each time; forms change without notice.
Attending Provider's Reporting Form
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Within 30 calendar days of the prescription date. The attending provider attaches all supporting documentation and mails the package to the Department of Health's Office of Planning, Policy, and Program Development. DOH asks that no patient information be faxed or emailed.
The form requires not less than 5 days between the first and second oral requests and not less than 48 hours between receipt of the written request and the prescription. The attending provider initials either that these periods passed or that all waiting periods are waived.
The forms were revised effective July 1, 2024 for 2023 amendments to the Act. APRNs may now act as attending or consulting providers, and the waiting period was shortened. The current reporting form lets the provider check APRN or physician and initial a waiver of all waiting periods.