Under Vermont's Patient Choice at End of Life law (18 V.S.A. Chapter 113), the prescribing physician refers the patient to a second physician for medical confirmation. This one-page Department of Health form records that consultation: the patient's name and date of birth, the referring physician, four confirmations, and the consultant's attestation that the Act's requirements have been met to the best of their knowledge.
The consulting physician completes the whole form, printing their name, phone number and mailing address in Section D and signing the attestation. Section B names the referring or prescribing physician, who receives the finished form.
Download the current version from the source each time; forms change without notice.
Consulting Physician Reporting Form
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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The Department of Health says use of its Patient Choice forms is not mandatory; they are provided to help patients and physicians meet the law's mandatory reporting requirements. The determinations themselves are still required: the form notes that both the attending and consulting physicians must confirm diagnosis and prognosis, capability, an informed decision and a voluntary request.
The prescribing physician. The form tells the consultant to deliver it to the attending or prescribing physician, who mails it to the Department's Vital Records office. The Department reviews the filed forms and links them to build a complete patient and physician record of each event.