When the attending or consulting physician refers a patient requesting medical aid in dying under New Jersey law for a determination of capability, the mental health professional records the result on form MAID-2. It states whether the patient is or is not capable and confirms that the attending physician was told in writing. It then joins the attending physician's compliance filing with the state.
The mental health professional who received the referral, such as a psychiatrist, psychologist or clinical social worker, completes and signs the one-page form, listing the referring physician's details and their own contact details.
Download the current version from the source each time; forms change without notice.
Mental Health Professional Compliance 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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The mental health professional to whom the attending physician or consulting physician referred the patient for a determination of capability under the Medical Aid in Dying Act, P.L. 2019, c.59. This can be a psychiatrist, psychologist or clinical social worker, who signs and dates the authorization section of the form.
To the attending physician. The attending appends it to the Attending Physician Compliance Form, which must be filed with the Office of the Chief State Medical Examiner no later than 30 days after the patient's death, either by mail or by email as digitally signed forms.