When a Vermont physician writes a prescription under the Patient Choice at End of Life law (18 V.S.A. Chapter 113), this two-page Department of Health form documents compliance. It records the patient's diagnosis and state of residence, the dates of the first and second oral requests and the written request, the physician's determinations and disclosures, the referral for a second opinion, and the steps taken when prescribing.
The prescribing (attending) physician completes and signs the whole form. The consulting physician records their own confirmation on the separate Consulting Physician Reporting Form.
Download the current version from the source each time; forms change without notice.
Physician 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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Reporting is required; this particular form is not. The Department of Health provides its Patient Choice forms to help with the law's mandatory reporting requirements and states that their use is not mandatory. The Department reviews filed forms and links them into a complete patient and physician record of each event.
Section C2 states that the second oral request must be made 15 days or more after the first. The form records the date of each oral request and of the written request, and Section D records when the written request was signed, the second oral request, and when the patient was offered the chance to rescind.