Hawaii's Our Care, Our Choice Act requires a consulting provider to independently confirm a patient's eligibility for medical aid in dying. After examining the patient and reviewing records, the consulting provider records the diagnosis, prognosis and exam date and checks that they verified terminal illness, a prognosis of 6 months or less, capacity, voluntariness and an informed decision.
The consulting provider, a Hawaii-licensed physician or APRN qualified by specialty or experience, completes and signs the form, which also records the attending provider's details.
Download the current version from the source each time; forms change without notice.
Consulting Provider's Confirmation and Verification 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.
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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A physician or APRN licensed in Hawaii who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding the patient's illness. The form asks the consulting provider to check APRN or physician and give contact details and island.
That they examined the patient and relevant medical records, confirmed the attending provider's diagnosis of terminal illness and prognosis of 6 months or less, and found the patient capable, acting voluntarily and making an informed decision. The form is then returned to the attending provider.