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Death with Dignity Forms via PDF

( ORS 127.800 - 127.897

Patient form


Provider forms
​or  Attending Physician Short Form - Revised 11/2015
Please Note: All information required in the standard two-page Attending Physician Form must be included in accompanying copies of the patient's chart notes. (See Attending Physician Form.) Most physicians use the two-page form to avoid call-backs for missing data items. 
  •  Pharmacy Dispensing Record Form  - Revised 11/2015
  • Attending Physician Follow-Up Form - Revised 11/2015
    Data collected from follow-up interviews with physicians. This document may be completed by the attending physician in lieu of a follow-up interview. NOTE: Older versions of this form will not longer be accepted by OHA after June 1, 2010.​

OHA form (internal use only)


 

The envelope used to return all forms should be marked as CONFIDENTIAL and mailed to:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Craig New


Hard copies of the rules and reporting forms can be obtained by emailing dwda.info@state.or.us or contacting us at:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Craig New
Phone (971) 673-1150 ​​​​​​​​​​​​​​​