The American Clinicians Academy on Medical Aid in Dying Patient-to-Doctor Referral System:

If you have a terminal condition and are considering aid in dying, we will refer you to physicians who can consider your aid-in-dying request.  The requirements are that you:
*Live in a state where aid in dying is legal
*Have a terminal diagnosis with a less than six-month prognosis
*Have the capacity to make your own medical decisions.

Please be sure to ask your present doctors about your request. If they are not experienced with aid in dying, let them know that the Academy’s physicians will work with them on the details, from the law to the medications used. There is no charge for this and they do not have to be a member of the Academy. Please share our contact information with your doctors: [email protected]

If you have approached your doctors about medical aid in dying and continue to need a referral to a physician who will participate, please fill out our referral intake form below.

Here are some details about Completing the Path to Medical Aid in Dying.

Here is an explanation of the Potential Fees and Expenses for Medical Aid in Dying. Please read this.

Submitting this form is your permission for us to share your information with potential aid-in-dying physicians and other related health care providers who may participate in your evaluation for and/or care related to medical aid in dying.

NOTE: Please pay attention to the details of the questions below, and answer completely. Partial information will lead to a delay in the referral.

If you complete this form and enter “Submit” and are not taken to the confirmation page, you have left required fields blank and we will not receive your form. Please fill in the missing fields and then Submit the form.

If you enter “Submit” and are not taken to the confirmation page, you have left required fields blank and we will not receive your form. Please fill in the missing fields and then re-submit the form.