Form MAID-7 "Attending Physician Compliance Form" - New Jersey

What Is Form MAID-7?

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-7 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-7 "Attending Physician Compliance 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 COMPLIANCE FORM
ATTENDING PHYSICIAN COMPLIANCE FORM
Filing Instructions:
Filing Instructions:
1.
1.
Must be completed by the attending physician who determined whether the person was a “qualified terminally ill patient”
Must be completed by the attending physician who determined whether the person was a “qualified terminally ill patient”
and met the other legal requirements for receiving medication under the Medical Aid in Dying Act (P.L.2019, c.59).
and met the other legal requirements for receiving medication under the Medical Aid in Dying Act (P.L.2019, c.59).
2.
Under P.L.2019, c.59, this form must be filed as soon as possible and no later than 30 days after the date of the qualified
2.
Under P.L.2019, c.59, this form must be filed as soon as possible and no later than 30 days after the date of the qualified
terminally ill patient’s death.
terminally ill patient’s death.
3.
Forms shall be filed with the New Jersey Office of the Chief State Medical Examiner at:
3.
Forms shall be filed with the New Jersey Office of the Chief State Medical Examiner at:
120 South Stockton Street, 3rd floor
PO Box 182
PO Box 360
Trenton, NJ 08625
Trenton, NJ 08625
Or you may submit your documents and your digitally signed forms via email to OCSME staff at maid@doh.nj.gov.
An electronic submission process is forthcoming. Any changes or additional submission processes will be posted to the
4.
The following forms must be appended for this form to be complete:
Department of Health website.
(1) Copy of the Request for Medication to End My Life in a Humane and Dignified Manner
4.
The following forms must be appended for this form to be complete:
(2) Consulting Physician Compliance Form
(1) Copy of the Request for Medication to End My Life in a Humane and Dignified Manner
(3) Mental Health Professional Compliance Form (if applicable)
(2) Consulting Physician Compliance Form
5.
After a patient’s death and submission of these materials, the New Jersey Office of the Chief State Medical Examiner will
(3) Mental Health Professional Compliance Form (if applicable)
contact the listed attending physician with follow-up questions necessary for appropriate death certificate filing.
5.
After a patient’s death and submission of these materials, the New Jersey Office of the Chief State Medical Examiner will
contact the listed attending physician with follow-up questions necessary for appropriate death certificate filing.
Date of Report Mailing: ____________________
Date of Report Mailing: ____________________
[Month/Day/Year]
[Month/Day/Year]
PATIENT INFORMATION
PATIENT INFORMATION
PATIENT INFORMATION
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s Name:
Patient’s Name:
Patient’s
Patient’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Month/Day/Year]
[Month/Day/Year]
Patient’s
Patient’s
Date of Birth:
Date of Birth:
Name:
Date of Birth:
Patient’s Mailing
Patient’s Mailing
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Patient’s
[Street Address]
[City, State, Zip Code]
Address:
Address:
Mailing Address:
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
Physician’s
Physician’s
Physician’s
Physician’s
Physician’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
[10-digit]
[Last Name, First Name, Middle Name]
Physician’s
Name:
Name:
Telephone
Telephone
Telephone
Name:
Number:
Number:
Number:
Physician’s
Physician’s
Physician’s
Facility Name:
Facility Name:
Facility Name:
[Street Address]
[City, State, Zip Code]
Physician’s
Physician’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Physician’s
Mailing Address:
Mailing Address:
Mailing Address:
Physician’s
Physician’s
Physician’s
License Number:
License Number:
License Number:
CONSULTING PHYSICIAN INFORMATION
CONSULTING PHYSICIAN INFORMATION
CONSULTING PHYSICIAN INFORMATION
Physician’s
Physician’s
Physician’s
Physician’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Physician’s
[10-digit]
[10-digit]
[10-digit]
[Last Name, First Name, Middle Name]
Physician’s
Name:
Name:
Telephone
Telephone
Telephone
Name:
Number:
Number:
Number:
Physician’s
Physician’s
Physician’s
Facility Name:
Facility Name:
Facility Name:
Physician’s
Physician’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
[Street Address]
[City, State, Zip Code]
Physician’s
Mailing Address:
Mailing Address:
Mailing Address:
Physician’s
Physician’s
Physician’s
License Number:
License Number:
License Number:
MAID-7
Blank forms available at:
Blank forms available at:
http://nj.gov/health/maid
http://nj.gov/health/maid
AUGUST 19
Page 1 of 5
MAID-7
OCT 21
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 COMPLIANCE FORM
ATTENDING PHYSICIAN COMPLIANCE FORM
Filing Instructions:
Filing Instructions:
1.
1.
Must be completed by the attending physician who determined whether the person was a “qualified terminally ill patient”
Must be completed by the attending physician who determined whether the person was a “qualified terminally ill patient”
and met the other legal requirements for receiving medication under the Medical Aid in Dying Act (P.L.2019, c.59).
and met the other legal requirements for receiving medication under the Medical Aid in Dying Act (P.L.2019, c.59).
2.
Under P.L.2019, c.59, this form must be filed as soon as possible and no later than 30 days after the date of the qualified
2.
Under P.L.2019, c.59, this form must be filed as soon as possible and no later than 30 days after the date of the qualified
terminally ill patient’s death.
terminally ill patient’s death.
3.
Forms shall be filed with the New Jersey Office of the Chief State Medical Examiner at:
3.
Forms shall be filed with the New Jersey Office of the Chief State Medical Examiner at:
120 South Stockton Street, 3rd floor
PO Box 182
PO Box 360
Trenton, NJ 08625
Trenton, NJ 08625
Or you may submit your documents and your digitally signed forms via email to OCSME staff at maid@doh.nj.gov.
An electronic submission process is forthcoming. Any changes or additional submission processes will be posted to the
4.
The following forms must be appended for this form to be complete:
Department of Health website.
(1) Copy of the Request for Medication to End My Life in a Humane and Dignified Manner
4.
The following forms must be appended for this form to be complete:
(2) Consulting Physician Compliance Form
(1) Copy of the Request for Medication to End My Life in a Humane and Dignified Manner
(3) Mental Health Professional Compliance Form (if applicable)
(2) Consulting Physician Compliance Form
5.
After a patient’s death and submission of these materials, the New Jersey Office of the Chief State Medical Examiner will
(3) Mental Health Professional Compliance Form (if applicable)
contact the listed attending physician with follow-up questions necessary for appropriate death certificate filing.
5.
After a patient’s death and submission of these materials, the New Jersey Office of the Chief State Medical Examiner will
contact the listed attending physician with follow-up questions necessary for appropriate death certificate filing.
Date of Report Mailing: ____________________
Date of Report Mailing: ____________________
[Month/Day/Year]
[Month/Day/Year]
PATIENT INFORMATION
PATIENT INFORMATION
PATIENT INFORMATION
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s Name:
Patient’s Name:
Patient’s
Patient’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[Month/Day/Year]
[Month/Day/Year]
Patient’s
Patient’s
Date of Birth:
Date of Birth:
Name:
Date of Birth:
Patient’s Mailing
Patient’s Mailing
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Patient’s
[Street Address]
[City, State, Zip Code]
Address:
Address:
Mailing Address:
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
ATTENDING PHYSICIAN INFORMATION
Physician’s
Physician’s
Physician’s
Physician’s
Physician’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
[10-digit]
[Last Name, First Name, Middle Name]
Physician’s
Name:
Name:
Telephone
Telephone
Telephone
Name:
Number:
Number:
Number:
Physician’s
Physician’s
Physician’s
Facility Name:
Facility Name:
Facility Name:
[Street Address]
[City, State, Zip Code]
Physician’s
Physician’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Physician’s
Mailing Address:
Mailing Address:
Mailing Address:
Physician’s
Physician’s
Physician’s
License Number:
License Number:
License Number:
CONSULTING PHYSICIAN INFORMATION
CONSULTING PHYSICIAN INFORMATION
CONSULTING PHYSICIAN INFORMATION
Physician’s
Physician’s
Physician’s
Physician’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
Physician’s
[10-digit]
[10-digit]
[10-digit]
[Last Name, First Name, Middle Name]
Physician’s
Name:
Name:
Telephone
Telephone
Telephone
Name:
Number:
Number:
Number:
Physician’s
Physician’s
Physician’s
Facility Name:
Facility Name:
Facility Name:
Physician’s
Physician’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
[Street Address]
[City, State, Zip Code]
Physician’s
Mailing Address:
Mailing Address:
Mailing Address:
Physician’s
Physician’s
Physician’s
License Number:
License Number:
License Number:
MAID-7
Blank forms available at:
Blank forms available at:
http://nj.gov/health/maid
http://nj.gov/health/maid
AUGUST 19
Page 1 of 5
MAID-7
OCT 21
New Jersey Department of Health
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
ATTENDING PHYSICIAN COMPLIANCE FORM
PATIENT ELIGIBILITY DETERMINATION
PATIENT INFORMATION
[Last Name, First Name, Middle Name]
[La
[Month/Day/Year]
Patient’s
Patient’s
Name:
Date of Birth:
Terminal Illness, Disease, or Condition:
_____________________________________________________
CHECK ALL THAT APPLY:
Made the initial determination of whether a patient is terminally ill, is capable, and has
voluntarily made the request for medication pursuant to P.L.2019, c.59 (C.26:16-1 et al.).
Required that the patient demonstrate New Jersey residency pursuant to section 11 of P.L.2019,
c.59 (C.26:16-11).
Informed the patient of all of the following:
1. The patient’s medical diagnosis and prognosis.
2. The potential risks associated with taking the medication to be prescribed.
3. The probable result of taking the medication to be prescribed.
4. The feasible alternatives to taking the medication, including, but not limited to, concurrent or
additional treatment opportunities, palliative care, comfort care, hospice care, and pain
control.
Referred the patient to a consulting physician for medical confirmation of the diagnosis and
prognosis, and for a determination that the patient is capable and acting voluntarily.
Referred the patient to a mental health care professional or determined that such a referral is not
appropriate, pursuant to section 8 of P.L.2019, c.59 (C.26:16-8).
Recommended that the patient participate in a consultation concerning concurrent or additional
treatment opportunities, palliative care, comfort care, hospice care, and pain control options for
the patient, and provided the patient with a referral to a health care professional qualified to
discuss these options with the patient.
Advised the patient about the importance of having another person present if and when the patient
chooses to self-administer medication prescribed under P.L.2019, c.59 (C.26:16-1 et al.) and of
not taking the medication in a public place.
Informed the patient of the patient’s opportunity to rescind the request at any time and in any
manner.
Offered the patient an opportunity to rescind the request at the time the patient made a second
oral request as provided in section 10 of P.L.2019, c.59 (C.26:16-10).
Fulfilled the medical record documentation requirements of P.L.2019, c.59 (C.26:16-1 et al.).
Requests for Medication:
First Oral Request Date:
___________________ Time of Request: __________________
[Month/Day/Year]
[12-Hour Format AM/PM
Written Request Submission Date:
___________________ Time of Request: __________________
[Month/Day/Year]
[12-Hour Format AM/PM]
Second Oral Request Date:
___________________ Time of Request: __________________
[Month/Day/Year]
[12-Hour Format AM/PM
Blank forms available at:
http://nj.gov/health/maid
Page 2 of 5
MAID-7
OCT 21
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 COMPLIANCE FORM
ATTENDING PHYSICIAN COMPLIANCE FORM
PATIENT INFORMATION
[La
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s Mental Status:
Patient’s
Patient’s
Name:
Date of Birth:
CHECK ONE:
Patient’s Mental Status:
In my medical opinion, the patient requesting medication is capable.
In my medical opinion, the patient may not be capable. I subsequently referred the patient to a
CHECK ONE:
mental health care professional (listed below) who notified me in writing that that mental health
care professional determined that the patient is capable.
In my medical opinion, the patient requesting medication is capable.
In my medical opinion, the patient may not be capable. I subsequently referred the patient to a
MENTAL HEALTH PROFESSIONAL’S INFORMATION (IF APPLICABLE)
MENTAL HEALTH PROFESSIONAL’S INFORMATION (IF APPLICABLE)
mental health care professional (listed below) who notified me in writing that that mental health
Professional’s
Professional’s
Professional’s
Professional’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
care professional determined that the patient is capable.
Name:
Name:
Telephone
Telephone
MENTAL HEALTH PROFESSIONAL’S INFORMATION
Number:
Number:
Professional’s
Professional’s
Professional’s
[10-digit]
[Last Name, First Name, Middle Name]
Professional’s
Facility Name:
Facility Name:
Telephone
Name:
Number:
Professional’s
Professional’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Professional’s
Mailing Address:
Mailing Address:
Facility Name:
Professional’s
Professional’s
[Street Address]
[City, State, Zip Code]
Professional’s
License Number:
License Number:
Mailing Address:
Professional’s
DISPENSING HEALTH CARE PROVIDER INFORMATION
DISPENSING HEALTH CARE PROVIDER INFORMATION
License Number:
The attending physician may dispense medication(s) directly, if the attending physician is authorized
The attending physician may dispense medication(s) directly, if the attending physician is authorized
under law to dispense and has a current federal DEA certificate of registration, or contact a pharmacist
under law to dispense and has a current federal DEA certificate of registration, or contact a pharmacist
who shall dispense the medication in accordance with P.L. 2019, c.59.
who shall dispense the medication in accordance with P.L. 2019, c.59.
DISPENSING HEALTH CARE PROVIDER INFORMATION
Provider’s Name:
Provider’s Name:
Provider’s
Provider’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
The attending physician may dispense medication(s) directly, if the attending physician is authorized under law to
Telephone
Telephone
dispense and has a current federal DEA certificate of registration, or contact a pharmacist who shall dispense the
medication in accordance with P.L. 2019, c.59.
Number:
Number:
Provider’s
Provider’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
[Last Name, First Name, Middle Name]
Provider’s
[10-digit]
Provider’s
Mailing Address:
Mailing Address:
Telephone
Name:
Number:
[Street Address]
[City, State, Zip Code]
Provider’s
MEDICATION PRESCRIBED
Mailing Address:
Medication Name
Quantity
Date Prescribed
[Month/Day/Year]
MEDICATION PRESCRIBED
Medication Name
Quantity
Date Prescribed
[Month/Day/Year]
May attach additional pages as necessary.
MAID-7
Blank forms available at:
http://nj.gov/health/maid
AUGUST 19
Blank forms available at:
http://nj.gov/health/maid
MAID-7
Page 3 of 5
OCT 21
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 COMPLIANCE FORM
ATTENDING PHYSICIAN COMPLIANCE FORM
Patient’s Mental Status:
PATIENT INFORMATION
[La
[Last Name, First Name, Middle Name]
[Month/Day/Year]
CHECK ONE:
Patient’s
Patient’s
Name:
Date of Birth:
In my medical opinion, the patient requesting medication is capable.
In my medical opinion, the patient may not be capable. I subsequently referred the patient to a
mental health care professional (listed below) who notified me in writing that that mental health
MEDICATION PRESCRIBED CONTINUED
care professional determined that the patient is capable.
Medication Name
Quantity
Date Prescribed
[Month/Day/Year]
MENTAL HEALTH PROFESSIONAL’S INFORMATION (IF APPLICABLE)
MENTAL HEALTH PROFESSIONAL’S INFORMATION (IF APPLICABLE)
Professional’s
Professional’s
Professional’s
Professional’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
Name:
Name:
Telephone
Telephone
Number:
Number:
Professional’s
Professional’s
Facility Name:
Facility Name:
Professional’s
Professional’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Mailing Address:
Mailing Address:
Professional’s
Professional’s
License Number:
License Number:
DISPENSING HEALTH CARE PROVIDER INFORMATION
DISPENSING HEALTH CARE PROVIDER INFORMATION
The attending physician may dispense medication(s) directly, if the attending physician is authorized
The attending physician may dispense medication(s) directly, if the attending physician is authorized
under law to dispense and has a current federal DEA certificate of registration, or contact a pharmacist
under law to dispense and has a current federal DEA certificate of registration, or contact a pharmacist
who shall dispense the medication in accordance with P.L. 2019, c.59.
who shall dispense the medication in accordance with P.L. 2019, c.59.
Provider’s Name:
Provider’s Name:
Provider’s
Provider’s
[Last Name, First Name, Middle Name]
[Last Name, First Name, Middle Name]
[10-digit]
[10-digit]
Telephone
Telephone
Number:
Number:
Provider’s
Provider’s
[Street Address]
[Street Address]
[City, State, Zip Code]
[City, State, Zip Code]
Mailing Address:
Mailing Address:
MEDICATION PRESCRIBED
Medication Name
Quantity
Date Prescribed
[Month/Day/Year]
May attach additional pages as necessary.
MAID-7
Blank forms available at:
http://nj.gov/health/maid
Blank forms available at:
http://nj.gov/health/maid
AUGUST 19
MAID-7
Page 4 of 5
OCT 21
New Jersey Department of Health
MEDICAL AID IN DYING FOR THE TERMINALLY ILL ACT
ATTENDING PHYSICIAN COMPLIANCE FORM
PATIENT INFORMATION
[La
[Last Name, First Name, Middle Name]
[Month/Day/Year]
Patient’s
Patient’s
Name:
Date of Birth:
CHECK ONE
Method prescription was delivered to a pharmacist:
In person.
By Permissible Electronic Communication.
By Mail.
Not applicable. I directly dispensed the medication.
AUTHORIZATION
Signature: _________________________________________ Date: ___________________
[Month/Day/Year]
Blank forms available at:
http://nj.gov/health/maid
Page 4 of 4
MAID-7
OCT 21
Page 5 of 5
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