AB1078,7,23 (4) At the time an individual makes the second oral request, the individual's attending provider shall offer the individual an opportunity to rescind the request.

AB1078,8,2 (5) Oral and written requests for medical aid in dying may be made only by the requesting individual and may not be made by the individual's surrogate decision-maker, health care proxy, attorney-in-fact for health care, or through an advance health care directive.

AB1078,8,6 (6) If an individual decides to transfer care to another provider, the former provider shall transfer all relevant medical records, including written documentation of the date of the individual's request or requests concerning medical aid in dying.

AB1078,8,12 156.11 Form of written request. (1) A valid written request for medication under this chapter shall be signed and dated by the requesting individual, and witnessed by at least one person who, in the presence of the requesting individual, attests that, to the best of the witness's knowledge and belief, the individual is capable, acting voluntarily, and is not being coerced nor unduly influenced to sign the request.

AB1078,8,14 (2) The witness required under this section must be a person who is not any of the following:

AB1078,8,15 (a) A relative of the requesting individual by blood, marriage, or adoption.

AB1078,8,18 (b) A person who at the time the request is signed would be entitled to any portion of the estate of the requesting individual upon death under any will or by operation of law.

AB1078,8,20 (c) An owner, operator, or employee of a health care facility where the requesting individual is receiving medical treatment or is a resident.

AB1078,8,22 (3) The requesting individual's attending provider at the time the request is signed may not be a witness.

AB1078,8,23 (4) The requesting individual's interpreter may not be a witness.

AB1078,8,25 (5) The written request for medication shall be in substantially the following form:

AB1078,9,1 REQUEST FOR MEDICATION

AB1078,9,2 TO END MY LIFE IN A

AB1078,9,3 PEACEFUL MANNER

AB1078,9,6 I, .... (insert name), am an adult of sound mind. I have been diagnosed with .... (insert description of terminal disease), and given a prognosis of six months or less to live.

AB1078,9,11 I have been fully informed of the feasible alternatives, 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.

AB1078,9,16 I 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, that I am under no obligation to fill the prescription once written nor to self-administer the medication if I obtain it.

AB1078,9,20 I 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.

AB1078,9,21 I make this request voluntarily, free from coercion or undue influence.

AB1078,9,22 Signed: ....

AB1078,9,23 Dated: ....

AB1078,9,24 Witness Signature: ....

AB1078,9,25 Dated: ....

AB1078,10,3 156.13 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:

AB1078,10,5 (a) Determine whether the individual has a terminal disease with a prognosis of six months or less and is mentally capable.

AB1078,10,9 (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 and except for an interpreter as necessary.

AB1078,10,10 (c) Inform the individual of all of the following:

AB1078,10,11 1. The individual's diagnosis.

AB1078,10,12 2. The individual's prognosis.