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
- 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:
- Written Request for Medication to End My Life in a Humane and Dignified Manner form, DOH 422-063 (PDF), or in substantially the same form as described in the act
- Attending Physician's Compliance form, DOH 422-064 (PDF)
- Consulting Physician's Compliance form, DOH 422-065 (PDF)
- Psychiatric/Psychological Consultant's Compliance form, DOH 422-066 (PDF), if an evaluation was performed.
- 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:
- 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.