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California EOLA Consulting Physician's Compliance Form

Under California's End of Life Option Act, a consulting physician must also confirm a patient's eligibility before an aid-in-dying drug is prescribed. On this two-page form the consultant records the terminal disease and exam dates, checks that the patient has a terminal disease, has capacity, is acting voluntarily and is fully informed, and documents mental status, including any mental health specialist referral.

Who completes it

The consulting physician completes and signs the form with name, mailing address and phone, and enters the attending physician's name and phone. The attending physician completes the separate checklist.

Submitting and payment

How to submit it
The attending physician submits it to CDPH within 30 calendar days of writing the prescription, with the checklist and a copy of the patient's written request, through the EOLA Online Forms Portal, by mail or by fax.

Good to know

  • The form notes that both the attending and the consulting physician must make these determinations, so the consultant's findings stand alongside, not in place of, the attending physician's.
  • Fully informed means the patient knows the diagnosis, prognosis, risks and potential result of the drug, and feasible alternatives such as comfort care, hospice, palliative care and pain control.
  • Section D requires one mental status choice. A mental health specialist means a psychiatrist or licensed psychologist, and capacity is defined under Probate Code section 4609.
  • SB 403, signed October 3, 2025, removed the Act's expiration date (Health and Safety Code 443 to 443.22).

Get the official form

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

Consulting Physician's Compliance 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

Who sends the California consulting physician form to CDPH?

The attending physician. CDPH's instructions list it among the forms the attending physician must submit within 30 calendar days of writing the prescription, together with the Attending Physician's Checklist and a copy of the patient's written request, through the portal, by mail or by fax.

What does the California consulting physician confirm?

That the patient has a terminal disease, has the capacity to make medical decisions, is acting voluntarily, and decided after being fully informed of diagnosis, prognosis, risks, likely result and alternatives. The consultant also states whether they found capacity themselves or referred the patient to a psychiatrist or licensed psychologist.

Can the EOLA consulting physician form be signed electronically?

CDPH says its EOLA Online Forms Portal lets all of the required forms be completed online, electronically signed and submitted directly to CDPH. The PDF version can also be completed, signed and given to the attending physician for mailing or faxing with the other forms.