The DC Death with Dignity Act requires a second physician to examine a patient requesting covered medication. The consulting physician uses this form to record the diagnosis, prognosis and examination date, confirm terminal disease, capacity, voluntariness and an informed decision, and state whether the patient was referred for psychiatric or psychological evaluation. The attending physician uploads it in DC Health's portal.
The consulting physician completes the consultant's report, the mental status determination and the consultant's information, and signs with a DC license number.
Download the current version from the source each time; forms change without notice.
Consulting 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.
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The form is addressed to the attending physician. DC Health's sample forms are for instruction only; the attending physician records the consultation in the online Death with Dignity module and uploads the consultant's form there, along with the date the consultation was requested.
The consulting physician must determine that the patient has a terminal disease, is capable, is acting voluntarily and has made an informed decision. The physician also records the medical diagnosis, prognosis and examination date, and whether a referral was made for a possible disorder causing impaired judgment.