Under the District's Death with Dignity Act of 2016, the attending physician documents each step of a patient's request for covered medication on this form. It records the oral and written requests, determinations of terminal disease, prognosis, capacity, residency and voluntariness, the consultations, and the prescription. Physicians enter it in DC Health's online module; the PDF is an instructional sample.
The attending physician completes every section and signs electronically. The consulting physician and any psychiatric or psychological consultant complete their own forms, which the attending physician uploads.
Download the current version from the source each time; forms change without notice.
Attending Physician's Compliance Form
DC Health, Health Regulation and Licensing Administration takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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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The second oral request must be made at least 15 days after the first oral request, and no less than 48 hours may elapse between the patient's written request and writing the prescription. The form records the date of each request and the date the covered medication was prescribed.
No. DC Health says its PDFs are for instructional purposes only and physicians enter the required information in the online module. The portal also handles correspondence with consulting physicians, psychologists, pharmacists and patients, and sending, receiving and uploading forms.