Forms for Patients and Providers

Please note, all forms updated in May 2022. Please make sure to use the latest Adobe Acrobat (.pdf) fillable versions for all physician and pharmacy forms. You must physically sign and mail the forms to the Department of Health.

Patient Form

Provider Forms and Instructions

  1. To comply with the act, within thirty calendar days of writing a prescription for medication under this act, the attending physician shall send the following completed, signed, and dated forms:
  1. Within thirty 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, the attending physician shall complete and mail:
  1. To comply with the act, within thirty calendar days of dispensing medication, the dispensing health care provider shall file a copy of:

Mail Forms To:

State Registrar
Center for Health Statistics
P.O. Box 47856
Olympia, WA 98504-7856

Questions?

Providers, if you have questions about the forms, contact DeathwithDignity@DOH.WA.GOV.