Form MAID-6 "Request for Medication to End My Life in a Humane and Dignified Manner" - New Jersey

What Is Form MAID-6?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MAID-6 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form MAID-6 "Request for Medication to End My Life in a Humane and Dignified Manner" - New Jersey

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New Jersey Department of Health
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
Upon completion of this form, the New Jersey Department of Health:
1. Requires that the Attending Physician retain a copy of this form. This completed form must be attached to Attending
Physician Compliance Form, which must be filed with the Office of the Chief State Medical Examiner no later than 30 days
after the date of the qualified terminally ill patient’s death.
2. Advises the Patient to retain a copy of this form. If a Patient intends to self-administer prescribed medications outside of a
facility, the Department of Health encourages the patient to leave this form in view when the medication is ingested to
facilitate timely reporting.
3. To report the death of the Patient listed on this form, please notify the New Jersey Department of Health at 973-648-4500.
I, _____________________________________________________________, am an adult of sound mind
[Last Name, First Name, Middle Name]
and a resident of New Jersey. I am suffering from ___________________________________________,
[Terminal Illness, Disease, or Condition]
which my attending physician has determined is a terminal illness, disease, or condition and which has
been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and
potential associated risks, the expected result; and feasible alternatives, including concurrent or additional
treatment opportunities, palliative care, comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that I may self-administer to end my life in a
humane and dignified manner and to contact any pharmacist as necessary to fill the prescription.
INITIAL ONE:
______
I have informed my family of my decision and taken their opinions into consideration.
______
I have decided not to inform my family of my decision.
______
I have no family to inform of my decision.
INITIAL ALL THAT APPLY:
______
My attending physician has recommended that I participate in a consultation concerning
concurrent or additional treatment opportunities, palliative care, comfort care, hospice care, and
pain control options, and provided me with a referral to a health care professional qualified to
discuss these options with me.
______
I have participated in a consultation concerning concurrent or additional treatment opportunities,
palliative care, comfort care, hospice care, and pain control options.
______
I am currently receiving palliative care, comfort care, or hospice care.
I understand that I have the right to rescind this request at any time.
I understand the full import of this request, and I expect to die if and when I take the medication to be
prescribed. I further understand that, although most deaths occur within three hours, my death may take
longer and my physician has counseled me about this possibility.
I make this request voluntarily and without reservation, and I accept full responsibility for my decision.
Signed: ______________________________________________________________________________
Dated: _________________________________ Time of Request: _______________________________
[Month/Day/Year]
[12-Hour Format AM/PM]
Blank forms available at:
http://nj.gov/health/maid
Page 1 of 2
MAID-6
AUGUST 20
New Jersey Department of Health
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
Upon completion of this form, the New Jersey Department of Health:
1. Requires that the Attending Physician retain a copy of this form. This completed form must be attached to Attending
Physician Compliance Form, which must be filed with the Office of the Chief State Medical Examiner no later than 30 days
after the date of the qualified terminally ill patient’s death.
2. Advises the Patient to retain a copy of this form. If a Patient intends to self-administer prescribed medications outside of a
facility, the Department of Health encourages the patient to leave this form in view when the medication is ingested to
facilitate timely reporting.
3. To report the death of the Patient listed on this form, please notify the New Jersey Department of Health at 973-648-4500.
I, _____________________________________________________________, am an adult of sound mind
[Last Name, First Name, Middle Name]
and a resident of New Jersey. I am suffering from ___________________________________________,
[Terminal Illness, Disease, or Condition]
which my attending physician has determined is a terminal illness, disease, or condition and which has
been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and
potential associated risks, the expected result; and feasible alternatives, including concurrent or additional
treatment opportunities, palliative care, comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that I may self-administer to end my life in a
humane and dignified manner and to contact any pharmacist as necessary to fill the prescription.
INITIAL ONE:
______
I have informed my family of my decision and taken their opinions into consideration.
______
I have decided not to inform my family of my decision.
______
I have no family to inform of my decision.
INITIAL ALL THAT APPLY:
______
My attending physician has recommended that I participate in a consultation concerning
concurrent or additional treatment opportunities, palliative care, comfort care, hospice care, and
pain control options, and provided me with a referral to a health care professional qualified to
discuss these options with me.
______
I have participated in a consultation concerning concurrent or additional treatment opportunities,
palliative care, comfort care, hospice care, and pain control options.
______
I am currently receiving palliative care, comfort care, or hospice care.
I understand that I have the right to rescind this request at any time.
I understand the full import of this request, and I expect to die if and when I take the medication to be
prescribed. I further understand that, although most deaths occur within three hours, my death may take
longer and my physician has counseled me about this possibility.
I make this request voluntarily and without reservation, and I accept full responsibility for my decision.
Signed: ______________________________________________________________________________
Dated: _________________________________ Time of Request: _______________________________
[Month/Day/Year]
[12-Hour Format AM/PM]
Blank forms available at:
http://nj.gov/health/maid
Page 1 of 2
MAID-6
AUGUST 20
New Jersey Department of Health
New Jersey Department of Health
New Jersey Department of Health
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
DECLARATION OF WITNESSES
DECLARATION OF WITNESSES
DECLARATION OF WITNESSES
By initialing and signing below on or after the date the person named above signs, we declare that the
By initialing and signing below on or after the date the person named above signs, we declare that the
By initialing and signing below on or after the date the person named above signs, we declare that the
person making and signing the above request:
person making and signing the above request:
person making and signing the above request:
Witness 1
Witness 1
Witness 1
Witness 2
Witness 2
Witness 2
_______
_______
_______
_______
_______
_______
1. Is personally known to us or has provided proof of identity.
1. Is personally known to us or has provided proof of identity.
1. Is personally known to us or has provided proof of identity.
_______
_______
_______
_______
_______
_______
2. Signed this request in our presence on the date of the person's
2. Signed this request in our presence on the date of the person's
2. Signed this request in our presence on the date of the person's
signature.
signature.
signature.
_______
_______
_______
_______
_______
_______
3. Appears to be of sound mind and not under duress, fraud, or undue
3. Appears to be of sound mind and not under duress, fraud, or undue
3. Appears to be of sound mind and not under duress, fraud, or undue
influence.
influence.
influence.
_______
_______
_______
_______
_______
_______
4. Is not a patient for whom either of us is the attending physician.
4. Is not a patient for whom either of us is the attending physician.
4. Is not a patient for whom either of us is the attending physician.
WITNESS 1
WITNESS 1
WITNESS 1
WITNESS 1
Printed Name
Printed Name
Printed Name
Dated:
Dated:
Dated:
Printed Name
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Month/Day/Year]
[Month/Day/Year]
[Month/Day/Year]
[Month/Day/Year]
Dated:
of Witness 1:
of Witness 1:
of Witness 1:
of Witness 1:
[12-Hour Format AM/PM]
Signature of
Signature of
Signature of
Signature of
Time of
Time of
Time of
Time of
[12-Hour Format AM/PM]
[12-Hour Format AM/PM]
[12-Hour Format AM/PM]
Witness 1:
Witness 1:
Witness 1:
Witness 1:
Declaration 1:
Declaration 1:
Declaration 1:
Declaration 1:
WITNESS 2
WITNESS 2
WITNESS 2
WITNESS 2
Printed Name
Printed Name
Printed Name
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Dated:
Dated:
Dated:
Dated:
[Month/Day/Year]
[Month/Day/Year]
[Month/Day/Year]
Printed Name
[Last Name, First Name, Middle Name]
[Month/Day/Year]
of Witness 2:
of Witness 2:
of Witness 2:
of Witness 2:
Signature of
Signature of
Signature of
Time of
Time of
Time of
Time of
[12-Hour Format AM/PM]
Signature of
[12-Hour Format AM/PM]
[12-Hour Format AM/PM]
[12-Hour Format AM/PM]
Witness 2:
Witness 2:
Witness 2:
Witness 2:
Declaration 2:
Declaration 2:
Declaration 2:
Declaration 2:
NOTE: At least one witness shall not be a relative by blood, marriage, or adoption of the person signing
NOTE: At least one witness shall not be a relative by blood, marriage, or adoption of the person signing
NOTE: At least one witness shall not be a relative by blood, marriage, or adoption of the person signing
this request, shall not be entitled to any portion of the person's estate upon the person’s death under any
this request, shall not be entitled to any portion of the person's estate upon the person’s death under any
this request, shall not be entitled to any portion of the person's estate upon the person’s death under any
will or by operation of law, and shall not own, operate, or be an owner, operator, or employee of a health
will or by operation of law, and shall not own, operate, or be an owner, operator, or employee of a health
will or by operation of law, and shall not own, operate, or be an owner, operator, or employee of a health
care facility, other than a long term care facility, where the person is a patient or resident. The person’s
care facility, other than a long term care facility, where the person is a patient or resident. The person’s
care facility, other than a long term care facility, where the person is a patient or resident. The person’s
attending physician at the time the request is signed shall not serve as a witness.
attending physician at the time the request is signed shall not serve as a witness.
attending physician at the time the request is signed shall not serve as a witness.
PATIENT’S DESIGNEE RESPONSIBLE FOR THE LAWFUL DISPOSAL OF THE
PATIENT’S DESIGNEE RESPONSIBLE FOR THE LAWFUL DISPOSAL OF THE
PATIENT’S DESIGNEE RESPONSIBLE FOR THE LAWFUL DISPOSAL OF THE
PATIENT’S DESIGNEE RESPONSIBLE FOR THE LAWFUL DISPOSAL OF THE MEDICATION(S)
MEDICATION(S)
MEDICATION(S)
MEDICATION(S)
Designee’s
[10-digit]
[Last Name, First Name, Middle Name]
Designee’s
Telephone
Name:
Designee’s
Designee’s
Designee’s
Designee’s
Designee’s
Designee’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
[10-digit]
Number:
Name:
Name:
Name:
Telephone
Telephone
Telephone
Designee’s
[Street Address]
[City, State, Zip Code]
Number:
Number:
Number:
Mailing Address:
Designee’s
Designee’s
Designee’s
[Street Address]
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
[City, State, Zip Code]
[Month/Day/Year]
Date of
Designee’s
Mailing Address:
Mailing Address:
Mailing Address:
Designation:
Signature:
Date of
Date of
Date of
Designee’s
Designee’s
Designee’s
[Month/Day/Year]
[Month/Day/Year]
[Month/Day/Year]
Designation:
Designation:
Designation:
Signature:
Signature:
Signature:
MAID-6
MAID-6
Blank forms available at:
Blank forms available at:
Blank forms available at:
http://nj.gov/health/maid
http://nj.gov/health/maid
http://nj.gov/health/maid
AUGUST 19
AUGUST 19
Page 2 of 2
MAID-6
AUGUST 20
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