The Death with Dignity Act only provides immunity from civil and criminal liability and disciplinary action for good faith compliance. All forms are required, must be complete, and submitted on time to the Department of Health. The Department of Health will contact providers if the forms are missing information. We keep all information strictly confidential and only release aggregate information on an annual basis.
Patient Written Request Form
A qualified patient must make a written request to an attending qualified medical provider in addition to the two oral requests, made at least seven days apart. The following form serves as the written request and must be physically signed by the qualified patient and two witnesses. The qualified patient must give the completed form to their attending qualified medical provider.
The attending qualified medical provider must submit the completed form within 30 calendar days of writing a prescription for a lethal dose of medication to the Department of Health.
Provider Forms and Instructions
Attending Qualified Medical Provider
As the attending qualified medical provider, you:
- Determine whether a patient is qualified under the Death with Dignity Act.
- Ensure the patient is making an informed decision.
- Refer the patient to a consulting qualified medical provider.
- Refer the patient for counseling if appropriate.
- Ensure all requirements under the Death with Dignity Act are met before prescribing medication.
- Submit completed forms to the Department of Health.
1. You must submit the following completed forms within 30 calendar days of writing a prescription for a lethal dose of medication:
- Written Request for Medication to End My Life in a Humane and Dignified Manner form (DOH 422-063), or a similar form
- Attending Qualified Medical Provider Compliance form (DOH 422-064)
- Consulting Qualified Medical Provider Compliance form (DOH 422-065)
- Psychiatric/Psychological Provider Compliance form (DOH 422-066), if an evaluation was performed.
2. You must submit the following completed form within 30 calendar days of a qualified patient's ingestion of a lethal dose of medication obtained under the act, or death from any other cause, whichever comes first:
Send the completed forms to the Department of Health.
- Online through REDCap: https://redcap.link/DeathWithDignity
- By fax: 360-200-7408
- By mail: Center for Health Statistics, PO Box 47856, Olympia, WA 98504-7856
Consulting Qualified Medical Provider
As the consulting qualified medical provider, you:
- Examine the patient and their medical records to confirm whether a patient is qualified under the Death with Dignity Act.
- Refer the patient for counseling if appropriate.
- Immediately after examination, submit the completed Consulting Qualified Medical Provider Compliance form (DOH 422-065) to the Attending Qualified Medical Provider. Do not send the form to the Department of Health directly.
Psychiatric/Psychological Provider
As the psychiatric/psychological provider, you:
- Examine the patient to determine if they have a psychiatric or psychological disorder or depression causing impaired judgment.
- Immediately after examination, complete and return the Psychiatric/Psychological Provider Compliance form (DOH 422-066) to the medical provider who referred the patient to you, either the Attending Qualified Medical Provider or Consulting Qualified Medical Provider.
Dispensing Provider/Pharmacist
As the dispensing health care provider, you must submit the following completed form within 30 calendar days of dispensing the prescribed medication.
Send the completed form to the Department of Health.
- Online through REDCap: https://redcap.link/DeathWithDignity
- By fax: 360-200-7408
- By mail: Center for Health Statistics, PO Box 47856, Olympia, WA 98504-7856
Questions
Health care providers, if you have questions about the forms or requirements, contact DeathwithDignity@DOH.WA.GOV.