A prescribing health care provider may provide a prescription for medical aid in dying medication to an individual only after the prescribing health care provider has:

A. determined that the individual has: (1)     capacity;

(2)     a terminal illness;

(3)     voluntarily made the request for medical aid in dying; and

(4)     the ability to self-administer the medical aid in dying medication;

B. provided medical care to the individual in accordance with accepted medical standards of care;

C. determined that the individual is making an informed decision after discussing with the individual the:

(1)     individual’s medical diagnosis and prognosis;

(2)     potential risks associated with self-administering the medical aid in dying medication that the individual has requested the health care provider to prescribe;

(3)     probable result of self-administering the medical aid in dying medication to be prescribed;

(4)     individual’s option of choosing to obtain the medical aid in dying medication and then deciding not to use it; and

(5)     feasible alternative, concurrent or additional treatment opportunities, including hospice care and palliative care focused on relieving symptoms and reducing suffering;

D. determined in good faith that the individual’s request does not arise from coercion or undue influence by another person;

E. noted in the individual’s health record the prescribing health care provider’s determination that the individual qualifies to receive medical aid in dying;

F. confirmed in the individual’s health record that at least one physician or osteopathic physician licensed pursuant to the Medical Practice Act [N.M. Stat. Ann. Chapter 61, Article 6] or the Osteopathic Medicine Act [N.M. Stat. Ann. Chapter 61, Article 10] has determined, after conducting an appropriate examination, that the individual has capacity, a terminal illness and the ability to self-administer the medical aid in dying medication. That physician may be the prescribing health care provider pursuant to this section, the individual’s hospice health care provider or another physician who meets the requirements of this subsection; G. affirmed that the individual is:

(1)     enrolled in a medicare-certified hospice program; or

(2)     eligible to receive medical aid in dying after the prescribing health care provider has referred the individual to a consulting health care provider, who has experience with the underlying condition rendering the qualified individual terminally ill, and the consulting health care provider has:

(a) examined the individual;

(b) reviewed the individual’s relevant medical records; and

(c) confirmed, in writing, the prescribing health care provider’s prognosis that the individual is suffering from a terminal illness; and

H. provided substantially the following form to the individual and enters the form into the individual’s health record after the form has been completed with all of the required signatures and initials:

“REQUEST FOR MEDICATION TO END MY LIFE IN A PEACEFUL MANNER I,                                                                                             , am an adult of sound mind.

I am suffering from a terminal illness, which is a disease or condition that is incurable and irreversible and that, according to reasonable medical judgment, will result in my death within six months. My health care provider has determined that the illness is in its terminal phase.         (Patient Initials) I have been fully informed of my diagnosis and prognosis, the nature of the medical aid in dying medication to be prescribed and the potential associated risks, the expected result and the feasible alternative, concurrent or additional treatment opportunities, including hospice care and palliative care focused on relieving symptoms and reducing suffering.         (Patient Initials) I request that my health care provider prescribe medication that will end my life in a peaceful manner if I choose to self-administer the medication, and I authorize my health care provider to contact a willing pharmacist to fulfill this request.             (Patient Initials) I understand that I have the right to rescind this request at any time.             (Patient Initials) I understand the full import of this request, and I expect to die if I self-administer the medical aid in dying medication prescribed. I further understand that although most deaths occur within three hours, my death may take longer. My health care provider has counseled me about this possibility.             (Patient Initials) I make this request voluntarily and without reservation.

Signed:                                                                                         Date:                                         Time:                                         DECLARATION OF WITNESSES:

We declare that the person signing this request:

1.     is personally known to us or has provided proof of identity;

2.     signed this request in our presence;

3.     appears to be of sound mind and not under duress, fraud or undue influence; and

4.     is not a patient for whom either of us is a health care provider.

Witness 1:                             Witness 2: Signature:                                                 Printed Name:                                             Relationship to Patient:                                                        Date:                                                                                                        .

NOTE: No more than one witness shall be a relative by blood, marriage or adoption of the person signing this request. No more than one witness shall own, operate or be employed at a health care facility where the person signing this request is a patient or resident.”.