AB781,,5959I have been fully informed of the feasible alternative, concurrent, or additional treatment opportunities for my terminal disease, including comfort care, palliative care, hospice care, or pain control, and the potential risks and benefits of each. I have been offered or received resources or referrals to pursue these alternative, concurrent, or additional treatment opportunities for my terminal disease. AB781,,6060I have been fully informed of the nature of the medication to be prescribed and the risks and benefits, including that the likely outcome of self-administering the medication is death. I understand that I can rescind this request at any time and that I am under no obligation to fill the prescription once written nor to self-administer the medication if I obtain it. AB781,,6161I request that my attending provider furnish a prescription for medication that will end my life in a peaceful manner if I choose to self-administer it, and I authorize my attending provider to contact a pharmacist to dispense the prescription at a time of my choosing. AB781,,6262I make this request voluntarily, free from coercion or undue influence. AB781,,6565Witness Signature: .... AB781,,6767156.13 Attending provider responsibilities. (1) The attending provider for an individual shall do all of the following with regard to requests for medication under this chapter: AB781,,6868(a) Determine whether the individual has a terminal disease with a prognosis of 6 months or less and is mentally capable. AB781,,6969(b) Confirm that the individual’s request for medication under this chapter does not arise from coercion or undue influence by asking the individual about coercion and influence outside the presence of other persons, except for an interpreter if necessary. AB781,,7070(c) Inform the individual of all of the following: AB781,,71711. The individual’s diagnosis. AB781,,72722. The individual’s prognosis. AB781,,73733. The potential risks, benefits, and probable result of self-administering the prescribed medication to bring about a peaceful death. AB781,,74744. The potential benefits and risks of feasible alternatives, including concurrent or additional treatment options for the individual’s terminal disease, palliative care, comfort care, hospice care, and pain control. AB781,,75755. The individual’s right to rescind the request for medication under this chapter at any time and in any manner. AB781,,7676(d) Inform the individual that there is no obligation to fill the prescription nor an obligation to self-administer the medication if it is obtained. AB781,,7777(e) Provide the individual with a referral for comfort care, palliative care, hospice care, pain control, or any other end-of-life treatment option as requested or as clinically indicated. AB781,,7878(f) Refer the individual to a consulting provider for medical confirmation that the individual requesting medication under this chapter both has a terminal disease with a prognosis of 6 months or less and is mentally capable. AB781,,7979(g) Include the consulting provider’s written determination, as provided under s. 156.15, in the individual’s medical record. AB781,,8080(h) Refer the individual to a licensed mental health care provider if the attending provider observes signs that the individual may not be capable of making an informed decision. AB781,,8181(i) Include the licensed mental health care provider’s written determination, as provided under s. 156.17, in the individual’s medical record if such determination was requested. AB781,,8282(j) Inform the individual of the benefits of notifying next of kin of the individual’s decision to request medication under this chapter. AB781,,8383(k) Fulfill all medical record documentation requirements. AB781,,8484(L) Ensure that all procedures required in order to fulfill a request for medication under this chapter are followed before providing a prescription to a qualified individual for medication under this chapter, including all of the following: AB781,,85851. Confirm that the individual has made an informed decision to obtain a prescription for medication under this chapter. AB781,,86862. Offer the individual an opportunity to rescind the request for medication under this chapter. AB781,,87873. Educate the individual on the recommended procedure for self-administering the medication to be prescribed; the safekeeping and proper disposal of unused medication in accordance with state and federal law; the importance of having another person present when the individual self-administers the medication to be prescribed; and not taking the medication in a public place.