Get Me Dhhs Attending Physician End-of-life Reporting Form 2019-2025

Filling out the ME DHHS Attending Physician End-of-Life Reporting Form is an important task for ensuring compliance with the state's Death with Dignity Act. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the form accurately and efficiently

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the patient information in section A. This includes the patient’s name (last, first, middle initial), date of birth, and medical diagnosis and prognosis.
3. Move to section B to provide your physician information. Fill in your name (last, first, middle initial), telephone number, mailing address, city, state, and ZIP code. Also include the consulting physician's name if applicable.
4. In section C, indicate the actions taken to comply with the law regarding the patient's oral and written requests. Check the boxes indicating the patient's first and second oral requests, including the dates and any relevant comments.
5. Continue in section C, recording the written request for medication that the patient made and the date of that request. Provide comments if necessary.
6. Proceed to the Attending Physician Determinations and Actions subsection in section C. Check the boxes indicating that the patient meets all requirements, such as being at least 18 years old and competent. Additionally, confirm steps taken for informed consent and patient understanding of the process.
7. For section D, enter the medication prescribed, including dosage, the date prescribed, and the pharmacist's name and address if applicable. Indicate the date the medication was dispensed and to whom.
8. Complete section E by identifying the principal source of medical coverage for the patient. Select the appropriate option from private insurance, government payor, Mainecare, self-pay, none, or unknown.
9. Finally, sign and date the form in the designated space for the physician's signature. Retain the original form in the patient's medical record and ensure a copy is provided to the State Registrar within 30 days of writing the prescription.

Begin filling out the ME DHHS Attending Physician End-of-Life Reporting Form online today.