State Forms

Attending Physician Compliance Form

Consulting Physician’s Compliance Form

Mental Health Professional Compliance Form

Medication Dispensing Record

Attending Physician’s Follow-up Form

Submission Instructions:

Under P.L.2019, c.59, the compliance forms and the Medication Dispensing Record must be filed with the New Jersey Department of Health.  Currently, the forms must be mailed to the Office of the Chief State Medical Examiner, 120 South Stockton Street, 3rd floor, PO Box 360, Trenton, NJ 08625.  An electronic submission process is forthcoming.  Any changes or additional submission processes will be posted here.

Sample Health System Policies

Sample Hospital Policy

Medical Aid in Dying: Best Practices for Developing Patient-Centered Policies