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Death with Dignity Forms

(ORS 127.800 - 127.897)

Patient form

Provider forms

  •  Attending Physician Form  - Revised 11/2015 or  Attending Physician Short Form - Revised 11/2015
    Please Note: All information required in the standard two-page Attending Physician Form must be included in accompanying copies of the patient's chart notes. (See Attending Physician Form.) Most physicians use the two-page form to avoid call-backs for missing data items.

OHA form (internal use only)

The envelope used to return all forms should be marked as CONFIDENTIAL and mailed to:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Craig New

Contact Us

Center for Health Statistics staff can answer inquiries about Oregon's Death with Dignity Act.

Email: dwda.info@state.or.us

Fax: 971-673-1201


How to order hard copies of the Death with Dignity forms

You may order hard copies of the rules and reporting forms by emailing dwda.info@state.or.us or contacting us at:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Craig New
Phone (971) 673-1150

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