New Mexico's Elizabeth Whitefield End-of-Life Options Act of 2021 requires the Department of Health to collect information on aid-in-dying medication prescribed. Prescribers report each prescription on the one-page EOL 1 form, revised 10/2023, which asks about the patient's gender, age at death, race or ethnicity, hospice enrollment, underlying condition and whether and when the medication was ingested.
The prescribing health care provider, a physician, nurse practitioner or physician assistant, completes and signs the whole form. New Mexico has no separate state forms for the consulting provider or a mental health evaluation.
Download the current version from the source each time; forms change without notice.
Medical Aid in Dying Reporting Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Within 30 days of prescribing the aid-in-dying medication. Because the outcome may not be known yet, the form allows answers of not yet ingested or unknown, and the provider then has up to 6 months to submit completed information, marked as a change or update.
According to the Department of Health, a New Mexico resident aged 18 or older with capacity to make an informed health care decision, a terminal illness with a life expectancy of six months or less, a voluntary request and the ability to self-administer. The prescribing clinician assesses eligibility, and a consulting provider confirms it.