* § 2899-k. Form of written request and witness attestation. 1. A\nrequest for medication under this article shall be in substantially the\nfollowing form:\n REQUEST FOR MEDICATION TO END MY LIFE\n I, _________________________________, am an adult who has\ndecision-making capacity, which means I understand and appreciate the\nnature and consequences of health care decisions, including the benefits\nand risks of and alternatives to any proposed health care, and to reach\nan informed decision and to communicate health care decisions to a\nphysician.\n I have been diagnosed with (insert diagnosis), which my attending\nphysician has determined is a terminal illness or condition, which has\nbeen medically confirmed by a consulting physician and mental health\nprofessional and will, in the judgment of the physicians and mental\nhealth professional, produce death within six months whether or not\ntreatment is provided.\n I have been fully informed of my diagnosis and prognosis, the nature\nof the medication to be prescribed and potential associated risks, the\nexpected result, and the feasible alternatives and treatment options\nincluding but not limited to palliative care and hospice care.\n I request that my attending physician prescribe medication that will\nend my life if I choose to take it, and I authorize my attending\nphysician to contact another physician or any pharmacist about my\nrequest.\n INITIAL ONE:\n ( ) I have informed or intend to inform one or more members of my\nfamily of my decision.\n ( ) I have decided not to inform any member of my family of my\ndecision.\n ( ) I have no family to inform of my decision.\n I understand that I have the right to rescind this request or decline\nto use the medication at any time.\n I understand the importance of this request, and I expect to die if I\ntake the medication to be prescribed. I further understand that although\nmost deaths occur within three hours, my death may take longer, and my\nattending physician has counseled me about this possibility.\n I make this request voluntarily, of my own volition and without being\ncoerced, and I accept full responsibility for my actions.\nSigned: __________________________\nDated: ___________________________\n DECLARATION OF WITNESSES\n I declare that the person signing this "Request for Medication to End\nMy Life":\n (a) is personally known to me or has provided proof of identity;\n (b) voluntarily signed the "Request for Medication to End My Life" in\nmy presence or acknowledged to me that the person signed it; and\n (c) to the best of my knowledge and belief, has decision-making\ncapacity and is making the "Request for Medication to End My Life"\nvoluntarily, of the person's own volition and is not being coerced to\nsign the "Request for Medication to End My Life".\n I am not the attending physician or consulting physician of the person\nsigning the "Request for Medication to End My Life" or the mental health\nprofessional who provides a decision-making capacity determination of\nthe person signing the "Request for Medication to End My Life" at the\ntime the "Request for Medication to End My Life" was signed.\n I further declare under penalty of perjury that the statements made\nherein are true and correct and false statements made herein are\npunishable.\n I further declare that I am not (i) related to the above-named patient\nby blood, marriage or adoption; (ii) entitled at the time the patient\nsigned the "Request for Medication to End My Life" to any portion of the\nestate of the patient upon such patient's death under any will or by\noperation of law, or otherwise in a position to benefit financially from\nthe patient's death; (iii) an owner, operator, employee or independent\ncontractor of a health care facility where the patient is receiving\ntreatment or is a resident; (iv) a domestic partner of the patient, as\ndefined in subdivision seven of section twenty-nine hu
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