SB499,9,25 156.11 Consulting physician confirmation. Before an attending physician may fulfill a request for medication under this chapter, a consulting physician shall examine the requester and his or her relevant patient health care records and shall medically confirm the attending physician's determinations that the requester suffers from a terminal disease, does not have incapacity, is making a request for medication voluntarily, and has made an informed decision. The consulting physician shall complete a written report regarding his or her findings and provide it to the attending physician for filing in the requester's patient health care record in compliance with the certification requirement of s. 156.09 (8) (g).

SB499,10,17 156.13 Referral for review and counseling. If in the opinion of the attending physician or the consulting physician a requester may be suffering from a psychiatric or psychological disorder, including depression, that causes impaired judgment, the attending physician or consulting physician shall refer the requester for review and counseling to a physician specializing in psychiatry or a licensed psychologist, as defined in s. 455.01 (4). If a referral is made by the attending or consulting physician, no request for medication may be fulfilled under this chapter unless the physician specializing in psychiatry, or the psychologist, to whom referral was made, determines and certifies in writing that the requester is not suffering from a psychiatric or psychological disorder, including depression, that causes impaired judgment. The attending physician shall file the certification in the requester's patient health care record under s. 156.09 (8) (d).

SB499,11,4 156.15 Written request for medication; form. The department shall prepare and provide copies of a request for medication authorization form and accompanying information for distribution in quantities to health care providers, hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar associations and individually to private persons. The department shall include, in information accompanying the copy of the request for medication authorization form, at least the statutory definitions of terms used in the request for medication authorization form, statutory restrictions on who may be witnesses to a valid request for medication under s. 156.07, and a statement explaining that valid witnesses acting in good faith are statutorily immune from civil or criminal liability. The request for medication authorization form distributed by the department shall be in the following form:

SB499,11,5 REQUEST FOR MEDICATION

SB499,11,6 AUTHORIZATION TO END MY LIFE IN A

SB499,11,7 HUMANE AND DIGNIFIED MANNER

SB499,11,9 I, .... (insert name), am an adult of sound mind, do not have incapacity, and am a resident of Wisconsin.

SB499,11,12 I am suffering from .... (insert description of terminal disease), which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.

SB499,11,15 I have been fully informed of my diagnosis, prognosis, 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.

SB499,11,17 I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.

SB499,11,18 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:

SB499,11,20 .... I have informed my family members of my decision and taken their opinions into consideration.

SB499,11,21 .... I have decided not to inform my family of my decision.

SB499,11,22 .... I have no family to inform of my decision.

SB499,11,23 I understand that I have the right to revoke this request at any time.

SB499,11,25 I understand the full import of this request and I expect to die when I take the medication to be prescribed.

SB499,12,2 I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.

SB499,12,3 Signed: ....

SB499,12,4 Dated: ....

SB499,12,5 Statement and signatures

SB499,12,6 of witnesses

SB499,12,16 I know the requester personally or I have received proof of his or her identity and I believe him or her to be of sound mind and at least 18 years of age. I believe that the requester makes this request voluntarily. I am at least 18 years of age, am not related to the requester by blood, marriage, or adoption, and am not directly financially responsible for the requester's health care. I am not a health care provider who is serving the requester at this time; an employee of the health care provider, other than a chaplain or a social worker; or an employee, other than a chaplain or a social worker, of a health care facility in which the requester is a patient. To the best of my knowledge, I am not entitled to and do not have a claim on the requester's estate.

SB499,12,17 Witness No. 1:

SB499,12,18 (print) Name: ....

SB499,12,19 Address: ....

SB499,12,20 Signature: ....

SB499,12,21 Witness No. 2:

SB499,12,22 (print) Name: ....

SB499,12,23 Address: ....