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Maine End-of-Life Closure Form: Death with Dignity

Maine DHHS requires every physician who writes a Death with Dignity prescription to file this one-page follow-up report. It asks whether the patient died from self-administering the medication, from the underlying illness, from another cause such as terminal sedation or stopping eating and drinking, or whether the cause is unknown, and how any unused medication was disposed of.

Who completes it

The attending physician completes and signs the whole form, entering the patient's name and date of birth. DHHS accepts it only with the attending physician's signature, whether or not the physician was present at the time of death.

Submitting and payment

How to submit it
Mail it to the attention of the State Registrar at Maine CDC within 30 calendar days of the patient's death, if the physician knows of it, or within 6 months of writing the prescription.

Good to know

  • If the cause of death or the disposal of unused medication is unknown, the form asks you to say so rather than leave the item blank.
  • Maine DHHS advises that unused, dispensed medication be delivered in person to a facility qualified to dispose of controlled substances, which is what the disposal question tracks.
  • It is a fillable PDF revised 06/2024. Information collected under the Act is confidential, is not a public record and is not open to public inspection.
  • It closes the reporting that began with the Attending Physician End-of-Life Reporting Form, which is due within 30 days of writing the prescription.

Get the official form

Download the current version from the source each time; forms change without notice.

End-of-Life Closure Form

Official pagePDF

How this list is checked

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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Frequently asked questions

When is Maine's End-of-Life Closure Form due?

Within 30 calendar days of the patient's death, if the death is known to the physician, or within 6 months of writing the Death with Dignity prescription. The form is mailed to the attention of the State Registrar at the Maine Center for Disease Control and Prevention, which keeps the information confidential.

Who signs the closure form if the physician was not at the death?

The attending physician still signs it. DHHS states that it will accept the form only when it is signed by the attending physician, whether or not that physician was present at the patient's time of death, so the prescriber remains responsible for filing it in every case.

What does the Maine End-of-Life Closure Form ask?

Besides the patient's name, date of birth and the attending physician's name, it asks one cause question with four choices: patient choice (self-administered medication), underlying illness, unknown, or other with a description. It then asks how any unused medication was disposed of, or that the disposal is unknown.