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Attending Physician End of Life Reporting Form 2019
MEDICAL COVERAGE/PATIENT INSURANCE What is the principal source of medical coverage for the patient a Private Insurance b Government Payor includes Medicare Indian Health Service or CHAMPUS c Mainecare or Medicaid d Self Pay e None f Unknown Revised 09/2019 To the best of my knowledge all of the requirements of the Death with Dignity Act 22 M. Dignified manner. 2. Attending physician has offered the patient an opportunity to rescind the request. Provide a copy of the completed form to the State...
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