ME DHHS Attending Physician End-of-Life Reporting Form 2019 free printable template

Maine Department of Health and Human Services Maine Center for Disease Control and Prevention 11 State House Station 220 Capitol Street Augusta, Maine 043330011 Tel; (207) 2875500; Toll Free: (888)

How to fill out ME DHHS Attending Physician End-of-Life Reporting

How to fill out ME DHHS Attending Physician End-of-Life Reporting Form

1. Obtain the ME DHHS Attending Physician End-of-Life Reporting Form from the official website or contact the relevant department.
2. Fill in the patient's information, including name, date of birth, and medical record number at the top of the form.
3. Complete the sections detailing the attending physician's name, medical license number, and contact information.
4. Provide information regarding the patient's diagnosis and the circumstances surrounding the end-of-life decision.
5. Ensure to include the date and time of death, along with the place of death.
6. Sign and date the form at the designated section to certify the information provided.
7. Submit the completed form to the appropriate department as specified on the form's instructions.

Who needs ME DHHS Attending Physician End-of-Life Reporting Form?

1. Attending physicians who are responsible for certifying the death and reporting the circumstances surrounding end-of-life decisions.
2. Healthcare facilities that require documentation for compliance with state reporting requirements.
3. Families of patients who may need the form for legal or administrative purposes.

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What is ME DHHS Attending Physician End-of-Life Reporting Form?

The ME DHHS Attending Physician End-of-Life Reporting Form is a document required for reporting the circumstances surrounding a patient's death when certain conditions are met, specifically in the context of end-of-life care.

Who is required to file ME DHHS Attending Physician End-of-Life Reporting Form?

Attending physicians who confirm a patient's death, particularly under circumstances related to end-of-life decisions, are required to file the ME DHHS Attending Physician End-of-Life Reporting Form.

How to fill out ME DHHS Attending Physician End-of-Life Reporting Form?

To fill out the ME DHHS Attending Physician End-of-Life Reporting Form, physicians need to provide specific patient details, circumstances of the death, methods of treatment, and other required information as stipulated in the form instructions.

What is the purpose of ME DHHS Attending Physician End-of-Life Reporting Form?

The purpose of the ME DHHS Attending Physician End-of-Life Reporting Form is to document and report the details of end-of-life decision-making, ensuring compliance with state regulations and contributing to public health data.

What information must be reported on ME DHHS Attending Physician End-of-Life Reporting Form?

The information that must be reported on the ME DHHS Attending Physician End-of-Life Reporting Form includes the patient's personal details, medical history, circumstances of death, the manner in which end-of-life care decisions were made, and any treatments administered.