Confidential Participating Physician Form – American Clinicians Academy on Medical Aid in Dying

Name*
First Last
Specialty*
Practice Email (to receive intakes)*
Practice Address*
Street Address City ZIP / Postal Code
Office Phone*
Counties your practice covers*
Willing to be the Attending (prescribing) physician for aid in dying?*
Willing to be a consulting physician for aid in dying?*
If you work with a healthcare organization, will you accept patients who are not enrolled in your organization? If so, please state which organization and/or any other details.*
Tell us a bit about your fee structure - are costs covered (ie - by insurance)? Or are your fees on sliding scale?*
Do you or your staff provide home visits and/or attendance during the aid-in-dying procedure?*
Can you or your staff help manage non-oral routes of administration?*
Please add any additional information if you think it would be helpful.
How did you learn about this form and referral system?
If you would like to receive the Academy's Clinical Updates, please list your email here