Once a patient who received a Death with Dignity prescription dies, from the medication or another cause, the attending provider completes this DOH questionnaire. It covers the underlying illness, insurance coverage, hospice status, the concerns behind the request, medication prescribed and dispensed, whether and where it was ingested, complications, EMS activation, and time to unconsciousness and death.
The attending qualified medical provider answers all 17 questions and signs the confirmation that, to the best of their knowledge, the Act's requirements were met.
Download the current version from the source each time; forms change without notice.
Attending Qualified Medical Provider After Death Reporting
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. DOH's forms page applies the 30-day deadline to death from any other cause as well as ingestion, and the form itself says to send it within 30 calendar days after the patient's death. Question 4 includes 'Patient did not ingest medication', and a No or Unknown answer to question 8 skips to the final question.
No. Questions 9 and 10 ask whether you were with the patient at ingestion and at death, with answers such as did not offer, offered but the patient declined, or another health care provider or someone else was present. DOH keeps the answers confidential and releases only aggregate data annually.