Under Oregon's Death with Dignity Act, when the attending or consulting physician refers a patient for evaluation, a psychiatrist or psychologist decides whether a psychiatric or psychological disorder, or depression, is impairing the patient's judgment. This one-page form, Rev. 5/18, records the evaluation and the consultant's conclusion. It becomes part of the attending physician's compliance packet sent to the state.
The psychiatrist or licensed psychologist who did the evaluation completes the form, listing the medical diagnosis, the dates of examination and a summary of the evaluation, and signs with their title, such as M.D. or Ph.D.
Download the current version from the source each time; forms change without notice.
Psychiatric/Psychological Consultant's Compliance Form
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Only when the attending or consulting physician refers the patient for evaluation of a possible psychiatric or psychological disorder, or depression, causing impaired judgment. OHA lists it with the attending physician's 7-day forms, marked if required, and the attending physician's form records the referral.
The attending or prescribing physician. The consultant delivers the completed form to that physician, who includes it with the attending physician's compliance form, the consulting physician's form and the patient's written request sent to the OHA Center for Health Statistics.