Section 146-15-3 - Responsibilities Of Healthcare ProvidersA.Compliance. The attending physician must verify that all requirements of the Act have been met before prescribing or dispensing life-ending medication. The attending physician is responsible for ensuring that copies of all required forms are received by the Department. The attending physician must ensure that each original, completed form is retained in the qualified patient's medical record. Copies of required forms must be filed within 30 days after the date the prescription for life-ending medication is written, unless otherwise specified.B.Request for Medication to End My Life in a Humane and Dignified Manner. The Request for Medication to End My Life in a Humane and Dignified Manner Form must be used for all written requests for life-ending medication. This form must be completed by the competent patient and two witnesses no sooner than 15 days following the patient's first oral request for life-ending medication, in accordance with 22 MRS §§2140(5) and 2140(24).A copy of the completed form must be provided to the qualified patient. 1.Witnesses. The qualified patient's signature on this form must be witnessed by at least two individuals who, in the presence of the qualified patient, attest that to the best of their knowledge and belief, the patient is competent, is acting voluntarily, and is not being coerced to sign the request. a. One witness must be a person who is not: i. A relative of the patient by blood, marriage, or adoption;ii. A person who at the time the form is signed would be entitled to any portion of the estate of the patient upon death, under any will or by operation of any law; or iii. An owner, operator or employee of a health care facility where the patient is receiving medical treatment or is a resident.b.Attending Physician. The patient's attending physician at the time the written request is signed may not be a witness.c.Patient in a Long-Term Care Facility. If the patient resides in a long-term care facility at the time of the patient's written request, one witness must be a licensed healthcare provider designated by the facility. The facility's designee may be an owner, operator or employee of the healthcare facility where the patient resides.C.Interpreter Attachment. The Interpreter Attachment Form is only required if an interpreter is used pursuant to 22 MRS §2140(5)(B), to interpret conversations or consultations between the patient and the patient's attending or consulting physician in a language other than English, regarding the written request for life-ending medication. If an interpreter is used, this form, containing the elements required by 22 MRS §2140(25), must accompany the Request for Medication to End My Life in a Humane and Dignified Manner Form.D.Consulting Physician End-of-Life Care Form. The Consulting Physician End-of-Life CareForm, containing the reporting requirements of 22 MRS §§2140(7) and 2140(14)(D), must be completed by the consulting physician who has examined the patient, has reviewed the patient's medical record, and who has confirmed the medical opinion of the attending physician that the patient is suffering from a terminal disease and has verified that the patient is competent, is acting voluntarily, and has made an informed decision.E.Attending Physician End-of-Life Reporting Form. The Attending Physician End-of-Life- Reporting Form must be completed by the attending physician to certify that all requirements of the Act have been met, including the attending physician's responsibilities at 22 MRS §2140(6), the documentation requirements at 22 MRS §2140(14), and the waiting periods set forth at 22 MRS §2140(13). A copy of the written prescription record must accompany this form.F.End-of-Life Closure Form. The End-of-Life Closure Form must be completed by the attending physician within 30 days after the qualified patient's death, in accordance with 22 MRS §2140(17)(B)(1). The Department, in receipt of a death certificate registration for a patient who has been prescribed life-ending medication, may contact the attending physician to complete reporting under this rule, including the End-of-Life Closure Form, and submit to the State Registrar within 30 days following notification of the patient's death.10-146 C.M.R. ch. 15, § 3