Form MAID-3 "Attending Physician Follow up Form" - New Jersey

What Is Form MAID-3?

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-3 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-3 "Attending Physician Follow up Form" - New Jersey

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New Jersey Department of Health
New Jersey Department of Health
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
ATTENDING PHYSICIAN FOLLOW UP FORM
ATTENDING PHYSICIAN FOLLOW UP FORM
Filing Instructions:
Filing Instructions:
1.
1.
This form is intended for use by the Office of the Chief State Medical Examiner to seek additional information from an
This form is intended for use by the Office of the Chief State Medical Examiner to seek additional information from an
Attending Physician under P.L. 2019, c. 59.
Attending Physician under P.L. 2019, c. 59.
2.
2.
Upon the receipt of the Attending Physician Compliance Form and/or a report of a death of a suspected Medical Aid in
Upon the receipt of the Attending Physician Compliance Form and/or a report of a death of a suspected Medical Aid in
Dying Patient, the Office of the Chief State Medical Examiner (OCSME) will contact the Attending Physician by phone to
Dying Patient, the Office of the Chief State Medical Examiner (OCSME) will contact the Attending Physician by phone to
facilitate accurate and timely death certificate completion and statistical reporting.
facilitate accurate and timely death certificate completion and statistical reporting.
3.
During follow-up, OCSME staff will seek any outstanding compliance forms or missing addenda.
3.
During follow-up, OCSME staff will seek any outstanding compliance forms or missing addenda.
4.
4.
If a patient’s death has not yet been filed in the Electronic Death Registration System (EDRS) at the time of follow-up,
If a patient’s death has not yet been filed in the Electronic Death Registration System (EDRS) at the time of follow-up,
OCSME will facilitate the completion of timely and accurate death certificate filing. This may necessitate asking additional
OCSME will facilitate the completion of timely and accurate death certificate filing. This may necessitate asking additional
questions required in EDRS.
questions required in EDRS.
Date of Filing: ____________________
Date of Filing: ____________________
[Month/Day/Year]
[Month/Day/Year]
PATIENT INFORMATION
REQUIRED PATIENT INFORMATION
REQUIRED PATIENT INFORMATION
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s
Patient’s
Patient’s Name:
Patient’s Name:
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Patient’s
Patient’s
[Month/Day/Year]
[Month/Day/Year]
Name:
Date of Birth:
Date of Birth:
Date of Birth:
Patient’s Cause of Death:
Patient’s Cause of Death:
ANSWER ONE
ANSWER ONE
Terminal Illness, Disease, or Condition with medical aid in dying.
Terminal Illness, Disease, or Condition with medical aid in dying.
Terminal Illness, Disease, or Condition without medical aid in dying.
Terminal Illness, Disease, or Condition without medical aid in dying.
Other: __________________________________________________________________
Other: __________________________________________________________________
COMPLIANCE INFORMATION
COMPLIANCE INFORMATION
Has the Attending Physician filed the Patient’s death in the Death Certificate in Electronic Death
Has the Attending Physician filed the Patient’s death in the Death Certificate in Electronic Death
Registration System (EDRS) Yet?
Registration System (EDRS) Yet?
ANSWER ONE
ANSWER ONE
Yes – Skip to Attending Information.
Yes – Skip to Attending Information.
No – OCSME will guide the Attending Physician through the EDRS filing process before
No – OCSME will guide the Attending Physician through the EDRS filing process before
continuing to Attending Information.
continuing to Attending Information.
Unknown – OCSME will guide the Attending Physician through the EDRS filing process before
Unknown – OCSME will guide the Attending Physician through the EDRS filing process before
continuing to Attending Physician Information. OCSME will notify the New Jersey Office of
continuing to Attending Physician Information. OCSME will notify the New Jersey Office of
Vital Statistics & Registry (OVSR) of potential duplicative death certificate filings.
Vital Statistics & Registry (OVSR) of potential duplicative death certificate filings.
Has the Attending Physician already submitted the required compliance forms to OCSME at DOH? If
Has the Attending Physician already submitted the required compliance forms to OCSME at DOH? If
not, request a complete report be filed within 30 days of the Patient’s death.
not, request a complete report be filed within 30 days of the Patient’s death.
CHECK ALL THAT APPLY
CHECK ALL THAT APPLY
Attending Physician Compliance Form
Attending Physician Compliance Form
Copy of the
Copy of the
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
Consulting Physician Compliance Form
Consulting Physician Compliance Form
(If Applicable) Mental Health Professional Compliance Form
(If Applicable) Mental Health Professional Compliance Form
MAID-3
Blank forms available at:
Blank forms available at:
http://nj.gov/health/maid
http://nj.gov/health/maid
AUGUST 19
Page 1 of 2
MAID-3
AUGUST 20
New Jersey Department of Health
New Jersey Department of Health
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
ATTENDING PHYSICIAN FOLLOW UP FORM
ATTENDING PHYSICIAN FOLLOW UP FORM
Filing Instructions:
Filing Instructions:
1.
1.
This form is intended for use by the Office of the Chief State Medical Examiner to seek additional information from an
This form is intended for use by the Office of the Chief State Medical Examiner to seek additional information from an
Attending Physician under P.L. 2019, c. 59.
Attending Physician under P.L. 2019, c. 59.
2.
2.
Upon the receipt of the Attending Physician Compliance Form and/or a report of a death of a suspected Medical Aid in
Upon the receipt of the Attending Physician Compliance Form and/or a report of a death of a suspected Medical Aid in
Dying Patient, the Office of the Chief State Medical Examiner (OCSME) will contact the Attending Physician by phone to
Dying Patient, the Office of the Chief State Medical Examiner (OCSME) will contact the Attending Physician by phone to
facilitate accurate and timely death certificate completion and statistical reporting.
facilitate accurate and timely death certificate completion and statistical reporting.
3.
During follow-up, OCSME staff will seek any outstanding compliance forms or missing addenda.
3.
During follow-up, OCSME staff will seek any outstanding compliance forms or missing addenda.
4.
4.
If a patient’s death has not yet been filed in the Electronic Death Registration System (EDRS) at the time of follow-up,
If a patient’s death has not yet been filed in the Electronic Death Registration System (EDRS) at the time of follow-up,
OCSME will facilitate the completion of timely and accurate death certificate filing. This may necessitate asking additional
OCSME will facilitate the completion of timely and accurate death certificate filing. This may necessitate asking additional
questions required in EDRS.
questions required in EDRS.
Date of Filing: ____________________
Date of Filing: ____________________
[Month/Day/Year]
[Month/Day/Year]
PATIENT INFORMATION
REQUIRED PATIENT INFORMATION
REQUIRED PATIENT INFORMATION
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s
Patient’s
Patient’s Name:
Patient’s Name:
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Patient’s
Patient’s
[Month/Day/Year]
[Month/Day/Year]
Name:
Date of Birth:
Date of Birth:
Date of Birth:
Patient’s Cause of Death:
Patient’s Cause of Death:
ANSWER ONE
ANSWER ONE
Terminal Illness, Disease, or Condition with medical aid in dying.
Terminal Illness, Disease, or Condition with medical aid in dying.
Terminal Illness, Disease, or Condition without medical aid in dying.
Terminal Illness, Disease, or Condition without medical aid in dying.
Other: __________________________________________________________________
Other: __________________________________________________________________
COMPLIANCE INFORMATION
COMPLIANCE INFORMATION
Has the Attending Physician filed the Patient’s death in the Death Certificate in Electronic Death
Has the Attending Physician filed the Patient’s death in the Death Certificate in Electronic Death
Registration System (EDRS) Yet?
Registration System (EDRS) Yet?
ANSWER ONE
ANSWER ONE
Yes – Skip to Attending Information.
Yes – Skip to Attending Information.
No – OCSME will guide the Attending Physician through the EDRS filing process before
No – OCSME will guide the Attending Physician through the EDRS filing process before
continuing to Attending Information.
continuing to Attending Information.
Unknown – OCSME will guide the Attending Physician through the EDRS filing process before
Unknown – OCSME will guide the Attending Physician through the EDRS filing process before
continuing to Attending Physician Information. OCSME will notify the New Jersey Office of
continuing to Attending Physician Information. OCSME will notify the New Jersey Office of
Vital Statistics & Registry (OVSR) of potential duplicative death certificate filings.
Vital Statistics & Registry (OVSR) of potential duplicative death certificate filings.
Has the Attending Physician already submitted the required compliance forms to OCSME at DOH? If
Has the Attending Physician already submitted the required compliance forms to OCSME at DOH? If
not, request a complete report be filed within 30 days of the Patient’s death.
not, request a complete report be filed within 30 days of the Patient’s death.
CHECK ALL THAT APPLY
CHECK ALL THAT APPLY
Attending Physician Compliance Form
Attending Physician Compliance Form
Copy of the
Copy of the
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
Consulting Physician Compliance Form
Consulting Physician Compliance Form
(If Applicable) Mental Health Professional Compliance Form
(If Applicable) Mental Health Professional Compliance Form
MAID-3
Blank forms available at:
Blank forms available at:
http://nj.gov/health/maid
http://nj.gov/health/maid
AUGUST 19
Page 1 of 2
MAID-3
AUGUST 20
New Jersey Department of Health
New Jersey Department of Health
New Jersey Department of Health
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
ATTENDING PHYSICIAN FOLLOW UP FORM
ATTENDING PHYSICIAN FOLLOW UP FORM
ATTENDING PHYSICIAN FOLLOW UP FORM
ATTENDING PHYSICIAN’S INFORMATION
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
Physician’s
Physician’s
Physician’s
Physician’s
Physician’s
Physician’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Physician’s
[10-digit]
[10-digit]
[10-digit]
[10-digit]
Physician’s
Name:
Name:
Name:
Telephone
Telephone
Telephone
Telephone
Name:
Number:
Number:
Number:
Number:
Physician’s
Physician’s
Physician’s
Physician’s
Facility Name:
Facility Name:
Facility Name:
Facility Name:
Physician’s
Physician’s
Physician’s
[Street Address]
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
[City, State, Zip Code]
[Street Address]
[City, State, Zip Code]
Physician’s
Mailing Address:
Mailing Address:
Mailing Address:
Mailing Address:
Physician’s
Physician’s
Physician’s
License Number:
License Number:
License Number:
Physician’s
License Number:
AUTHORIZATION BY OFFICE OF THE STATE CHIEF MEDICAL EXAMINER
AUTHORIZATION BY OFFICE OF THE STATE CHIEF MEDICAL EXAMINER
AUTHORIZATION BY OFFICE OF THE STATE CHIEF MEDICAL EXAMINER
OSCME Investigator’s Name:
OSCME Investigator’s Name:
OSCME Investigator’s Name:
Date: ___________________
Date: ___________________
Date: ___________________
[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]
MAID-3
MAID-3
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-3
AUGUST 20
Page of 2