When the attending or consulting provider refers a Death with Dignity patient for evaluation of a possible psychiatric or psychological disorder, or depression causing impaired judgment, the evaluating provider documents the result on this one-page DOH form. It lists the patient, the attending and consulting providers, the medical diagnosis, exam dates, the evaluation itself, and the evaluator's signed confirmation.
The psychiatric or psychological provider who examined the patient (a psychiatrist, psychologist, or psychiatric ARNP or clinical social worker as allowed under RCW 70.245) completes and signs the whole form.
Download the current version from the source each time; forms change without notice.
Psychiatric/Psychological Provider Compliance
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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To the medical provider who referred the patient, either the attending or consulting qualified medical provider, immediately after the exam. The attending provider then submits it to the Washington Department of Health with the other compliance forms within 30 calendar days of writing the prescription.
No. It is needed only when the attending or consulting provider referred the patient for a psychiatric or psychological evaluation. DOH lists it among the attending provider's 30-day submissions only if an evaluation was performed. When no referral was made, the attending and consulting forms record that the provider found no impaired judgment.