§ 7–661.02. Requests for a covered medication.
(a) To request a covered medication, a patient shall:
(1) Make 2 oral requests, separated by at least 15 days, to an attending physician.
(2) Submit a written request, signed and dated by the patient, to the attending physician before the patient makes his or her 2nd oral request and at least 48 hours before a covered medication may be prescribed or dispensed.
(b)(1) A written request made pursuant to subsection (a)(2) of this section shall be witnessed by at least 2 individuals who, in the presence of the patient, attest to the best of their knowledge and belief that the patient is capable, acting voluntarily, and is not being unduly influenced to sign the request.
(2) If the patient is a patient in a long-term care facility at the time the written request is made under subsection (a)(2) of this section, one of the witnesses shall be an individual designated by the facility who has met the qualifications specified in the Department's regulations.
(3) One of the witnesses shall be a person who is not:
(A) A relative of the patient by blood, marriage, or adoption;
(B) At the time the request is signed, entitled to any portion of the estate of the qualified patient upon death under any will or by operation of law; or
(C) An owner, operator, or employee of a health care facility where the qualified patient is receiving medical treatment or is a resident.
(4) The patient's attending physician at the time of the request shall not be a witness.
(c) A written request made pursuant to subsection (a)(2) of this section shall be in substantially the following form:
"REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND PEACEFUL MANNER
"I, _____________, am an adult of sound mind.
"I am suffering from ____________, which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.
"I have been fully informed of my diagnosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care, and pain control.
"I request that my attending physician prescribe medication that will end my life in a humane and peaceful manner.
"[ ] I have informed my family of my decision and taken their opinion into consideration.
"[ ] I have decided not to inform my family of my decision.
"[ ] I have no family to inform of my decision.
"I understand that I have the right to rescind this request as any time.
"I understand the full import of this request, and I expect to die when I take the medication to be prescribed. I further understand that although most deaths occur within 3 hours of taking the medication to be prescribed, 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 moral responsibility for my actions.
"DECLARATION OF WITNESSES:
"We declare that the person signing this request:
"(a) Is personally known to us or has provided proof of identity;
"(b) Signed this request in our presence;
"(c) Appears to be of sound mind and not under duress, fraud, or undue influence;
"(d) Is not a patient for whom either of us is the attending physician.
"Witness 1 signature:
"Witness 2 signature:
"NOTE: 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 death, and shall not own, operate, or be employed at the health care facility where the person is a patient or resident. If the patient is a patient at a long-term care facility, one of the witnesses shall be an individual designated by the facility.".