Get Form 5-7 End-of-life Option Act Attending Physician ...
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How to fill out the FORM 5-7 END-OF-LIFE OPTION ACT ATTENDING PHYSICIAN online
This guide provides clear, step-by-step instructions for filling out the FORM 5-7 END-OF-LIFE OPTION ACT ATTENDING PHYSICIAN online. Designed for individuals and healthcare providers, this guide ensures you have the necessary information to complete the form accurately and effectively.
Follow the steps to fill out the form correctly.
- Press the ‘Get Form’ button to access the form and open it in your preferred document editing interface.
- Begin with the patient information section. Fill in the patient's last name, first name, middle initial, date of birth, and address, ensuring all details are accurate.
- Proceed to the attending physician information section. Input the attending physician's full name, telephone number, mailing address, and license number.
- Next, complete the consulting physician information section with the required details about the consulting physician, using the same format as the attending physician section.
- Move on to the eligibility determination section. Confirm that you have completed the necessary assessments and mark the checkboxes for compliance, indicating determinations such as the patient's terminal disease status and residency in California.
- Review the additional compliance requirements. Ensure all required counseling and discussions with the patient are documented as required by the form.
- In the patient’s mental status section, check the appropriate box confirming the patient's ability to make medical decisions, documenting any referrals to mental health specialists if applicable.
- Complete the medication prescribed section by listing the aid-in-dying medication, dosage, antiemetic prescription, and method of delivery for the prescriptions.
- Finally, sign and date the form in the signature section, ensuring the physician's name is printed clearly.
- Once all sections are completed and verified for accuracy, save the changes made to the form. You can then download, print, or share the completed document as needed.
Complete your Form 5-7 online safely and efficiently today!
Patient must make three requests for the aid-in-dying drug to his or her attending physician – two orally (at least 15 days apart) and one in writing on a special form that is witnessed. Attending physician must be willing to prescribe an aid-in-dying drug and must make sure the patient legally qualifies.
Fill FORM 5-7 END-OF-LIFE OPTION ACT ATTENDING PHYSICIAN ...
Appendix C: End-Of-Life Option Act Attending Physician Checklist and Compliance Form. D. Appendix D: End-Of-Life Option Act Consulting Physician Compliance Form. Physician Compliance Form," and the "End of Life Option. Act Attending Physician Follow-Up Form. The End of Life Options Act (SB 128) went into effect on June 9, 2016. (HOSPITAL Form X) and place it as well as the completed Consulting. The California End of Life Option Act allows physicians to prescribe an aid-in-dying drug for individuals who qualify under the Act.
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