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

Filling out the ME DHHS Attending Physician End-of-Life Reporting Form is an essential process for ensuring compliance with state regulations regarding end-of-life care. This guide will help you navigate the form accurately and efficiently.

Follow the steps to complete the form accurately and responsibly.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin with Section A, where you will provide patient information. Fill in the patient's name, date of birth, and details of the medical diagnosis and prognosis.
3. Proceed to Section B to enter your physician information. Include your name, telephone number, mailing address, city, state, and ZIP code. Additionally, list the consulting physician’s name and contact information.
4. In Section C, describe the actions you took to comply with the law. Record your documentation of the first and second oral requests made by the patient, including dates and any comments.
5. Continue in Section C by indicating whether you have completed all required attending physician determinations and actions. Make sure to check each relevant box confirming the patient's age, diagnosis, competency, and voluntary request.
6. In Section D, document the medication prescribed and the corresponding dosage. Include the date the prescription was issued and the pharmacist's name and address if applicable.
7. In Section E, specify the patient's principal source of medical coverage by selecting one of the provided options.
8. Lastly, ensure that you provide your signature and the date, affirming that all Death with Dignity Act requirements have been met. If additional comments are necessary, use an attached page and reference the relevant sections.
9. Once completed, save any changes made to the form. You can download, print, or share the completed form as necessary to comply with submission requirements.

Complete the ME DHHS Attending Physician End-of-Life Reporting Form online today to ensure compliance and provide necessary documentation.