When a DC attending or consulting physician suspects a psychiatric or psychological disorder, or depression causing impaired judgment, the patient is referred for evaluation under the Death with Dignity Act. The psychiatrist or psychologist records the diagnosis, evaluation dates and findings, then states whether the patient is or is not suffering from such a disorder. The form goes to the attending physician.
A psychiatrist or psychologist completes the evaluation and consultant's information sections and signs with title and license number.
Download the current version from the source each time; forms change without notice.
Psychiatric/Psychological Consultant'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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Both the attending and consulting physicians must check either that the patient is not suffering from a disorder causing impaired judgment or that they referred the patient for evaluation. A referral to a psychiatrist or psychologist triggers this form, which documents the evaluation and the consultant's determination.
A psychiatrist or psychologist who evaluated the patient. The consultant signs with their title, such as M.D. or Ph.D., and license number, records the dates of examination and sends the form to the attending physician for the Death with Dignity record.