A consulting qualified medical provider must examine a patient who requests medication under Washington's Death with Dignity Act and review the records to confirm eligibility. This one-page DOH form captures that consultation: the exam date, the six determinations both providers must make, the information given to the patient, and whether a psychiatric or psychological referral was needed.
The consulting qualified medical provider completes and signs the whole form, including their contact details in Section E. The attending provider is identified in Section B and receives the finished form.
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Consulting Qualified Medical Provider Compliance
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No. The instructions say to complete and return the form to the attending qualified medical provider immediately after the examination and not to send it to DOH directly. The attending provider attaches it to the Attending Qualified Medical Provider Compliance Form (DOH 422-064) and submits both within 30 days of prescribing.
That the patient has a terminal disease with six months or less to live, is competent, is a Washington resident, is acting voluntarily, and decided after being fully informed. Both the attending and consulting providers must make these determinations, and the consultant also records whether a mental health evaluation referral was made.