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HB2569 - 572R - I Ver
REFERENCE TITLE:
terminally ill individuals; end-of-life decisions
State of Arizona
House of Representatives
Fifty-seventh Legislature
Second Regular Session
2026
HB 2569
Introduced by
Representatives
Mathis: De Los Santos, Gutierrez
AN
ACT
amending
title 36, Arizona Revised Statutes, by adding chapter 43; relating to end-of-life
decisions.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, Arizona Revised Statutes,
is amended by adding chapter 43, to read:
CHAPTER 43
MEDICAL AID IN DYING
ARTICLE 1. GENERAL
PROVISIONS
START_STATUTE
36-4301.
Definitions
In this article, unless the context otherwise
requires:
1. "Adult" means an
individual who is at least eighteen years of age.
2. "Attending physician"
means a person who is qualified by specialty or experience to determine an
individual's eligibility to pursue medical aid in dying under this article, who
agrees to write the prescriptions and who takes responsibility for counseling
the individual, making care decisions, ensuring compliance with this article
and submitting proper documentation to the department.
3. "Capacity" means an
individual's ability, as determined by professional standards of care, to
understand and appreciate health care options available to the individual,
including significant benefits and risks, and to make and communicate an
informed health care decision.
4. "Coercion or undue
influence" means the wilful attempt, whether by deception, intimidation or
any other means, to cause an individual to request, obtain or self-administer
medication pursuant to this article with intent to cause the death of the
individual or to prevent the individual from obtaining or self-administering
medication pursuant to this article.
5. "Consulting physician"
means a physician who is qualified by specialty or experience to make a
professional diagnosis and prognosis regarding an individual's disease.
6. "Counseling" means one
or more consultations as necessary between a mental health professional and an
individual to determine whether the individual has capacity and is not
suffering from a psychiatric or psychological disorder or depression causing
impaired judgment.
7. "Department" means the
department of health services.
8.
"Health
care facility":
(
a
)
Means a hospital, medical clinic, nursing home or inpatient hospice
facility or any other licensed health care institution where the delivery of
health care is facilitated.
(
b
) Does not
include an individual health care provider.
9. "Health care provider":
(
a
) Means a
person who is licensed, certified or otherwise authorized or allowed by the
laws of this state to administer health care or dispense medication in the
ordinary course of business or practice of a profession.
(
b
) Does not
include a health care facility.
10. "Informed decision"
means a voluntary affirmative decision that is all of the following:
(
a
) Made by a
qualified individual to request and obtain a prescription for medication that
the individual will self-administer to end the individual's life in a
humane and dignified manner.
(
b
) Based on an
appreciation of the relevant facts.
(
c
) Made after
the attending physician fully informs the individual of all of the following:
(
i
) The
individual's medical diagnosis.
(
ii
) The
individual's prognosis.
(
iii
) The potential
risks associated with taking the medication to be prescribed.
(
iv
) The
probable result of taking the medication to be prescribed.
(
v
) The
feasible alternatives and concurrent or additional treatment opportunities for
the individual's terminal illness, including comfort care, palliative care,
hospice care, pain control and disease-directed treatment options, as
well as the risks and benefits of each alternative.
11. "Medical aid in dying"
means the practice of evaluating a request from, determining qualification for
and providing a prescription for medication to a qualified individual pursuant
to this article.
12. "Medically confirm"
means that a consulting physician who has examined the individual and the
individual's relevant medical records confirms the medical opinion of the
attending physician.
13. "Mental health
professional" means a psychiatrist, psychologist or psychiatric nurse
practitioner who is licensed by this state.
14. "Physician" means a
physician who is licensed pursuant to title 32, chapter 13 or 17.
15. "Prescription for
medication" means a prescription that is written by an attending physician
for medication for a qualified individual to self-administer to bring about a
peaceful death in accordance with this article.
16. "Qualified individual"
means a terminally ill adult with capacity who is a resident of this state and
who has satisfied the requirements of this article in order to obtain a
prescription for medication.
17. "Self-administer":
(
a
) Means an affirmative, conscious voluntary act by a
qualified individual to ingest the prescription medication.
(
b
) Does not
include the administration of prescription medication by an injection or
intravenous infusion.
18. "Telemedicine" means
the delivery of health care services such as diagnosis, consultation or
treatment through the use of live interactive audio and video over a secure
connection that complies with the requirements of the health insurance
portability and accountability act (P.L. 104-191).
19. "Terminal illness" or
"terminally ill" means an incurable illness that will, within
reasonable medical judgment, result in death within six months.
END_STATUTE
START_STATUTE
36-4302.
Prescription for medication; written request; initiation
An adult resident of this state who has
capacity, whom the attending physician and consulting physician have determined
is suffering from a terminal illness and who has voluntarily expressed a wish
to die may make a written request for a prescription for medication.
END_STATUTE
START_STATUTE
36-4303.
Form of request; translation; witnesses; signatures
A. A valid request for a prescription
for medication must be in substantially the form described in section 36-4323,
be signed and dated by the qualified individual and be witnessed by two
individuals who, in the presence of the qualified individual, attest that to
the best of their knowledge and belief the qualified individual has capacity,
is acting voluntarily and is not being coerced to sign the
request. A person who does not speak english may have the written
request form translated into the person's primary language for signature.
B. One of the witnesses must be an
individual who is not any of the following:
1. Related to the qualified
individual by blood, marriage, adoption or registered domestic partnership.
2. At the time the request is signed,
entitled to any portion of the qualified individual's estate on the qualified
individual's death under any will or by operation of law.
3. At the time the request is signed,
the qualified individual's attending physician, consulting physician, mental
health professional or interpreter.
END_STATUTE
START_STATUTE
36-4304.
Attending physician; requirements
The attending physician shall do all of the
following:
1. Make the initial determination
whether an individual has a terminal illness, has capacity and has made the
request voluntarily.
2. Request the individual to
demonstrate residency in this state pursuant to section 36-4313.
3. Ensure that the individual is
making an informed decision by informing the patient of all of the following:
(
a
) The
individual's medical diagnosis.
(
b
) The
individual's prognosis.
(
c
) The
potential risks associated with taking the medication to be prescribed.
(
d
) The
probable result of taking the medication to be prescribed.
(
e
) Feasible alternatives and concurrent or additional
treatment opportunities for the individual's terminal illness, including
comfort care, palliative care, hospice care, pain control and disease-directed
treatment options, as well as the risks and benefits of each alternative.
4. Provide the individual with a
referral for comfort care, palliative care, hospice care, pain control or other
end-of-life treatment opportunities as requested or as clinically
indicated.
5. Confirm that the individual's
request does not arise from coercion or undue influence by asking the
individual about coercion and undue influence outside of the presence of other
persons, except an interpreter as necessary.
6. Discuss with the individual the
individual's right to rescind the request at any time.
7. Refer the patient individual to a
consulting physician to medically confirm the diagnosis and to determine that
the individual has capacity and is acting voluntarily and note this
determination in the individual's medical record.
8. Refer the individual to a mental
health professional for counseling if appropriate pursuant to section 36-4306
and note this determination in the individual's medical record.
9. Counsel the individual about the
importance of all of the following:
(
a
) Safely
keeping and disposing of all unused prescribed medication.
(
b
) The
recommended methods of self-administering the medications prescribed
under this article.
(
c
) Having
another person present when the individual takes the medication.
(
d
) Not taking
the medication in a public place.
(
e
) The
benefits of notifying the individual's next of kin.
10. Offer the individual an
opportunity to rescind at the end of the fifteen-day waiting period
prescribed in section 36-4311.
11. Immediately before writing the
prescription for medication, verify that the individual is making an informed
decision.
12. Either:
(
a
) If the
attending physician is authorized by state and federal law to dispense the
medication, dispense the medication directly, including any ancillary
medications intended to minimize the individual's discomfort.
(
b
) With the
individual's written consent, do both of the following:
(
i
) Contact a
pharmacist and inform the pharmacist of the prescription.
(
ii
) Deliver the written prescription for medication
personally or by other means to the pharmacist, who shall dispense the
medications to either the qualified individual, the attending physician or an
expressly identified agent of the qualified individual.
13. Document the qualified
individual's medical record as required in section 36-4312.
14. Ensure that all appropriate steps
are carried out in accordance with this article before writing a prescription
for medication.
END_STATUTE
START_STATUTE
36-4305.
Consulting physician; confirmation of diagnosis; requirements
Before an individual is deemed qualified under
this article, a consulting physician shall examine the individual and the
individual's relevant medical records, shall confirm in writing the attending
physician's diagnosis that the individual is suffering from a terminal illness
and shall verify that the individual has capacity, is acting voluntarily and
has made an informed decision
.
END_STATUTE
START_STATUTE
36-4306.
Counseling referral; prohibition
If the attending physician or the consulting
physician believes an individual may be suffering from a psychiatric or
psychological disorder or depression causing impaired judgment, either
physician shall refer the individual for counseling. The attending
physician may not write a prescription for medication until the person
performing the counseling determines that the individual is not suffering from
a psychiatric or psychological disorder or depression causing impaired judgment
and provides a written report.
END_STATUTE
START_STATUTE
36-4307.
Informed decision required; verification
The attending physician may not write a
prescription for medication unless the qualified individual has made an
informed decision.� Immediately before writing a prescription for medication,
the attending physician shall verify that the qualified individual is making an
informed decision.
END_STATUTE
START_STATUTE
36-4308.
Family notification
The attending physician shall recommend that the
qualified individual notify the qualified individual's next of kin regarding
the qualified individual's request for a prescription for medication.� If the
qualified individual declines or is unable to notify next of kin, the attending
physician may not deny the qualified individual's request for that reason
.
END_STATUTE
START_STATUTE
36-4309.
Use of interpreters
An interpreter whose services are provided to an
individual requesting information on care under this article shall meet the
standards adopted by the national council on interpreting in health care or
other standards deemed acceptable by the department for health care providers
in this state.� An interpreter who is used for the purposes of this article may
not:
1. Be related to the qualified
individual by blood, marriage, registered domestic partnership or adoption or
be entitled to a portion of the individual's estate on death.
2. Act as a witness for the
individual's written request
.
END_STATUTE
START_STATUTE
36-4310.
Right to rescind request; disposal of unused medication
A. A qualified individual may rescind
a request at any time and in any manner without regard to the qualified
individual's mental state. The attending physician may not write a
prescription for medication without offering the qualified individual an
opportunity to rescind the request.
B. If the attending physician writes
a prescription for medication and the qualified individual decides not to use
the medication to end the qualified individual's life, the unused medication
must be disposed of by any legal means or as prescribed by rule.
END_STATUTE
START_STATUTE
36-4311.
Oral request; written request; waiting period; waiver
A. To receive a prescription for
medication that a qualified individual may self-administer under this article,
the qualified individual must make an oral request to the attending physician
either in person or by telemedicine, if the attending physician determines the
use of telemedicine is clinically appropriate, and a written request with two
witnesses. A prescription for medication may not be written before
receipt of the qualified individual's written request and may not be written
until fifteen days after the initial oral request.
B. Notwithstanding subsection A of
this section, if the attending physician attests that the qualified individual
will, within reasonable medical judgment, die within fifteen days after making
the initial oral request and the written request has been submitted, the
fifteen-day waiting period may be waived
.
END_STATUTE
START_STATUTE
36-4312.
Medical records; documentation; requirements
All of the following shall be documented or
filed in the qualified individual's medical record:
1. All oral requests by the qualified
individual for a prescription for medication.
2. All written requests by the
qualified individual for a prescription for medication.
3. The attending physician's
diagnosis and prognosis and determination that the qualified individual has
capacity, is acting voluntarily and has made an informed decision.
4. The consulting physician's
diagnosis and prognosis and verification that the qualified individual has
capacity, is acting voluntarily and has made an informed decision.
5. A report of the outcome and
determinations made during counseling, if performed.
6. The attending physician's offer to
the qualified individual to rescind the qualified individual's request at the
time of the qualified individual's oral request.
7. A note from the attending
physician indicating that all requirements under this article have been met and
indicating the steps taken to carry out the request, including a notation of
any medications prescribed.
END_STATUTE
START_STATUTE
36-4313.
Residency requirement; definition
A. The
attending physician may grant an individual's request under this article only
if the individual's residence is in this state. An individual may
present any of the following to show the individual's residency under this
section:
1. A
valid Arizona driver license that contains the individual's physical residence
address.� A post office box is not a residence address for the purposes of this
paragraph.
2. A
valid Arizona nonoperating identification license that contains the
individual's physical residence address.� A post office box is not a residence
address for the purposes of this paragraph.
3. Evidence
that the individual owns or leases property in this state.
4. Proof
of voter registration in this state.
5. A
current income tax return that contains the individual's physical residence
address.� A post office box is not a residence address for the purposes of this
paragraph.
6. Any
other means of demonstrating residency acceptable to the attending physician.
B. For the purposes of this section,
"residence" means a place where a person has established a fixed and
principal home to which the person, whenever temporarily absent, intends to
return.
END_STATUTE
START_STATUTE
36-4314.
Annual records review; reporting requirements; confidentiality;
rules; annual report
A. The department shall annually
review a sample of records maintained pursuant to this article.
B. The department shall require a
health care provider, within thirty days after dispensing a prescription for
medication pursuant to this article, to file a copy of the dispensing record
with the department.
C. The department shall adopt rules
to facilitate the collection of information regarding compliance with this
article. Except as otherwise required by law, the information
collected is not a public record and is not available for inspection by the
public.
D. The department shall generate and
make available to the public an annual statistical report of information
collected under this section
.
END_STATUTE
START_STATUTE
36-4315.
Effect on construction of contracts, wills or agreements
A. A
provision in a contract, will or other agreement, whether written or oral, is
invalid to the extent that the provision would affect whether a qualified
individual may make or rescind a request for a prescription for medication.
B. An obligation owing under any
currently existing contract may not be conditioned on or affected by the making
or rescinding of a request by a qualified individual for a prescription for
medication
.
END_STATUTE
START_STATUTE
36-4316.
Insurance or annuity policies
The sale, procurement or issuance or delivery of
benefits under a life, health or accident insurance or annuity policy or the
rate charged for a policy may not be conditioned on or affected by the
availability of medication pursuant to this article or on a qualified
individual making or rescinding a request for a prescription for
medication. A qualified individual's act of ingesting medication to
end the individual's life in a humane and dignified manner does not affect a
life, health or accident insurance or annuity policy issued or delivered in
this state. the rating, sale, procurement or issuance of any medical
professional liability insurance policy in this state must be made in
accordance with title 20
.
END_STATUTE
START_STATUTE
36-4317.
Construction of article; standard of care
A. This article does not authorize a
health care provider or any other person to end a qualified individual's life
by lethal injection or subcutaneous infusions, mercy killing or active
euthanasia.
B. Actions taken in accordance with
this article do not, for any purpose, constitute suicide, assisted suicide,
mercy killing, elder abuse or homicide as prescribed in title
13. State reports may not refer to acts committed under this article
as suicide or assisted suicide. State reports must refer to acts
committed under this article as obtaining and self-administering life-ending
medication.
C. This
article does not lower the applicable standard of care for attending
physicians, consulting physicians, mental health professionals or other health
care providers who provide services under this article.
END_STATUTE
START_STATUTE
36-4318.
Health care facilities; transfer; coordination; duties
If a qualified individual wishes to transfer to
a different health care facility to receive medical aid in dying care, the
nonparticipating health care facility shall coordinate the transfer in a timely
manner, including the transfer of the qualified individual's medical records,
including a notation of the date that the individual first requested medical
aid in dying. The nonparticipating health care facility's referral
to a participating health care facility is not participation in medical aid in
dying but is deemed a medical standard of care.
END_STATUTE
START_STATUTE
36-4319.
Immunities; prohibiting a health care provider from
participation; permissible sanctions; definitions
A. Except
as provided in section 36-4321:
1. A health care provider or health
care facility is not subject to civil or criminal liability or professional
disciplinary action, including censure, suspension, loss of license, loss of
medical privileges, loss of membership or any other penalty, for engaging in
the practice of medical aid in dying in accordance with the standard of care
and in good faith compliance with this article.
2. A health care provider, health
care facility or professional organization or association may not subject a
health care provider to censure, discipline, suspension, loss of license, loss
of privileges, loss of membership or any other penalty for providing medical
aid in dying in accordance with the standard of care and in good faith pursuant
to this article or for providing scientific and accurate information about
medical aid in dying to an individual when discussing end-of-life
care options.
3. A health care provider is not
subject to civil or criminal liability or professional discipline if, with the
consent of the qualified individual, the health care provider is present when
the qualified individual self-administers medication prescribed pursuant
to this article or at the time of the qualified individual's death.
4. A request by a qualified
individual for or provision by an attending physician of a prescription for
medication in good faith compliance with this article does not constitute
neglect for any purpose of law or provide the sole basis for the appointment of
a guardian or conservator.
5. A health care provider is not
under any duty, whether by contract, statute or any other legal requirement, to
participate in providing a qualified individual prescribed medication to end
the qualified individual's life. If a health care provider is unable
or unwilling to carry out a qualified individual's request under this article
and the qualified individual transfers the qualified individual's care to a new
health care provider, the prior health care provider shall transfer, on
request, a copy of the qualified individual's relevant medical records to the
new health care provider.
6. Notwithstanding any other
provision of law, a health care provider may prohibit another health care
provider from participating in activities covered by this article on the
premises of the prohibiting health care provider if the prohibiting health care
provider has notified the health care provider of the prohibiting health care
provider's policy regarding participating in activities covered by this
article. This paragraph does not prevent a health care provider from
providing a qualified individual with health care services that do not
constitute participation in activities covered by this article.
7. Notwithstanding paragraphs 1, 2
and 3 of this subsection, a health care provider may subject another health
care provider to any of the following sanctions if the sanctioning health care
provider has notified the sanctioned health care provider before participating
in activities covered by this article that the actions are prohibited:
(
a
) Loss of
privileges, loss of membership or any other sanction provided pursuant to the
medical staff bylaws, policies and procedures of the sanctioning health care
provider if the sanctioned health care provider is a member of the sanctioning
health care provider's medical staff and participates in activities covered by
this article while on the health care facility premises of the sanctioning
health care provider, but not including the private medical office of a
physician or other health care provider.
(
b
) Termination
of lease or other property contract or other nonmonetary remedies provided by a
lease contract, not including loss or restriction of medical staff privileges
or exclusion from a provider panel, if the sanctioned health care provider
participates in activities covered by this article while on the premises of the
sanctioning health care provider or on property that is owned by or under the
direct control of the sanctioning health care provider.
(
c
) Termination
of contract or other nonmonetary remedies provided by contract if the
sanctioned health care provider participates in activities covered by this
article while acting in the course and scope of the sanctioned health care
provider's capacity as an employee or independent contractor of the sanctioning
health care provider. This subdivision does not prevent either of
the following:
(
i
) A health
care provider from participating in activities covered by this article while
acting outside the course and scope of the health care provider's capacity as
an employee or independent contractor.
(
ii
) A
qualified individual from contracting with the qualified individual's attending
physician and consulting physician to act outside the course and scope of the
health care provider's capacity as an employee or independent contractor of the
sanctioning health care provider.
8. A health care provider that
imposes sanctions pursuant to paragraph 7 of this subsection must follow all
due process and other procedures the sanctioning health care provider may have
that are related to imposing sanctions on another health care provider.
9. Action taken pursuant to section
36-4303, 36-4304, 36-4305 or 36-4306 may not be the
sole basis for a report of unprofessional conduct under title 32, chapter 13 or
17.
B. For the purposes of this section:
1. "Notify" means that a
sanctioning health care provider specifically informs a health care provider in
a separate statement in writing of the sanctioning health care provider's
policy about participating in activities covered by this article.
2. "Participate in activities
covered by this article":
(
a
) Means any
of the following:
(
i
) to perform
the duties of an attending physician pursuant to section 36-4304 or a
consulting physician pursuant to section 36-4305 or the counseling
function pursuant to section 36-4306.
(
ii
) To perform
the duties of a mental health professional if a referral to one is made.
(
iii
) To
deliver the prescription for medication, to dispense the prescribed medication
or to deliver the dispensed medication pursuant to this article.
(
iv
) To be
present when the qualified individual takes the medication prescribed pursuant
to this article.
(
b
) Does not
include making an initial determination that an individual has a terminal
disease and informing the individual of the medical prognosis, providing
information about this article to an individual on the individual's request or
providing an individual, on the individual's request, with a referral to
another health care provider for the purpose of assessing medical aid in dying
or an individual contracting with the individual's attending physician and
consulting physician to act outside of the course and scope of the health care
provider's capacity as an employee or independent contractor of the sanctioning
health care provider.
END_STATUTE
START_STATUTE
36-4320.
Death certificates
A. Unless otherwise prohibited by
law, the attending physician or the director of the health care facility where
a qualified individual terminated the qualified individual's life pursuant to
this article shall sign the death certificate of a qualified individual who
obtained and self-administered a prescription for medication pursuant to
this article.
B. When a death has occurred in
accordance with this article, the cause of death must be listed as the
underlying terminal illness. A qualified individual's act of
self-administering medication prescribed pursuant to this article may not be
included on the death certificate.
END_STATUTE
START_STATUTE
36-4321.
Violations; classification; liability
A. A person is guilty of a class 2
felony who, without the qualified individual's authorization, wilfully alters
or forges a request for a prescription for medication or conceals or destroys a
rescission of that request with the intent or effect of causing the qualified
individual's death.
B. A person is guilty of a class 2
felony who coerces or exerts undue influence on a qualified individual with a
terminal illness to request a prescription for medication pursuant to this
article with the intent or effect of causing the qualified individual's death.
C. A person is guilty of a class 2
felony who, without authorization of the qualified individual, wilfully alters,
forges, conceals or destroys an instrument, the reinstatement or revocation of
an instrument or any other evidence or document reflecting the qualified
individual's desires and interests, with the intent and effect of causing a
withholding or withdrawal of life-sustaining procedures or artificially
administered nutrition and hydration that hastens the death of the qualified
individual.
D. Except as provided in subsection C
of this section, a person is guilty of a class 1 misdemeanor who, without
authorization of the qualified individual, wilfully alters, forges or destroys
an instrument, or any other evidence or document reflecting the qualified
individual's desires and interests with the intent or effect of affecting a
health care decision of the qualified individual.
E. This article does not limit
further liability for civil damages resulting from other negligent conduct or
intentional misconduct by any person.
F. The penalties in this article do
not preclude criminal penalties applicable under other law for conduct that is
inconsistent with this article.
END_STATUTE
START_STATUTE
36-4322.
Claims by governmental entity; costs
A governmental entity that incurs costs
resulting from a qualified individual terminating the qualified individual's
life pursuant to this article in a public place has a claim against the estate
of the qualified individual to recover the costs and reasonable attorney fees
related to enforcing the claim
.
END_STATUTE
START_STATUTE
36-4323.
Prescription for medication; form of request
A request for
medication as authorized by this article shall be in substantially the
following form:
REQUEST FOR MEDICATION to END MY
LIFE
IN A HUMANE AND
DIGNIFIED MANNER
I,
(name of
individual)
, am an adult of sound mind.
I am suffering from
(description of
illness)
, which my attending physician has determined is a terminal
illness.
I have been fully informed of my diagnosis, my
prognosis, the potential risks associated with taking the medication to be
prescribed and the probable result of taking the medication. I have
been informed of the feasible alternatives and concurrent or additional
treatment opportunities, including comfort care, palliative care, hospice care,
pain control and disease-directed treatment options, as well as the risks
and benefits of each alternative.
I request that my attending physician
prescribe medication that will end my life in a humane and dignified manner,
should I choose to self-administer it.
I understand the full import of this request
and I expect to die when I take the medication to be prescribed. I
further understand that although most deaths occur within three hours, my death
may take longer and my attending physician has counseled me about this
possibility.
I make this request voluntarily and without
reservation.
qualified individual's signature:
______________________
Dated: ___________________________
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
to not be under duress, fraud or undue influence.
4. Is not a patient for whom either
of us is the attending physician.
Witness 1 Signature: ______________ Dated:
____________
Witness 2 signature: ______________ Dated:
____________
NOTE: One
witness cannot be a relative (by blood, marriage, registered domestic
partnership or adoption) of the qualified individual signing this request and
cannot be entitled to any portion of the qualified individual's estate on
death. The qualified individual's attending physician, consulting
physician, mental health professional and interpreter cannot be a witness.
END_STATUTE
START_STATUTE
36-4324.
Form of interpreter attachment
The form of an attachment for the purposes of providing interpreter
services must be in substantially the following form:
I, ____
(name of interpreter)
_____, am
fluent in English and
(language of qualified
individual)
. On
(date)
at approximately
(time)
,
I read the "Request for Medication to End my Life in a Humane and
Dignified Manner" to
(name of qualified individual)
in
(language
of qualified individual)
who affirmed to me that he/she understands the
content of this form, that he/she desires to sign this form under his/her own
power and volition and that he/she requested to sign this form after consulting
with an attending physician and a consulting physician.
Under penalty of perjury, I declare that I am
fluent in English and
(language of qualified individual)
and that the
contents of this form, to the best of my knowledge, are true and correct.
Executed at
(name of city, county and
state)
on
(date)
Interpreter's signature:
_____________________________
Interpreter's printed name:
__________________________
Interpreter's address:
_______________________________
END_STATUTE
Sec. 2.
Severability
If a provision of this act or its
application to any person or circumstance is held invalid, the invalidity does
not affect other provisions or applications of the act that can be given effect
without the invalid provision or application, and to this end the provisions of
this act are severable.
Sec. 3.
Short title
This act may be cited as the
"Thomas M. Dow Act".