C.R.S. Section 25-48-112
Form of written request

(1)

A request for medical aid-in-dying medication authorized by this article must be in substantially the following form:

Request for medication to end my life

in a peaceful manner

am an adult of sound mind. I am suffering from

, which my attending physician has determined is a terminal illness and which has been medically confirmed. I have been fully informed of my diagnosis and prognosis of six months or less, the nature of the medical aid-in-dying medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment opportunities, including comfort care, palliative care, hospice care, and pain control.

I request that my attending physician prescribe medical aid-in-dying medication that will end my life in a peaceful manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.

I understand that I have the right to rescind this request at any time.

I understand the seriousness of this request, and I expect to die if I take the aid-in-dying medication 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, without reservation, and without being coerced, and I accept full responsibility for my actions.

Signed:

Dated:

Declaration of witnesses

We declare that the individual signing this request:

Is personally known to us or has provided proof of identity;

Signed this request in our presence;

Appears to be of sound mind and not under duress, coercion, or undue influence; and

I am not the attending physician for the individual.

witness 1/date

witness 2/date

Note: Of the two witnesses to the written request, at least one must not:

Be a relative (by blood, marriage, civil union, or adoption) of the individual signing this request; be entitled to any portion of the individual’s estate upon death; or own, operate, or be employed at a health-care facility where the individual is a patient or resident.

And neither the individual’s attending physician nor a person authorized as the individual’s qualified power of attorney or durable medical power of attorney shall serve as a witness to the written request.

Source: Section 25-48-112 — Form of written request, https://leg.colorado.gov/sites/default/files/images/olls/crs2023-title-25.pdf (accessed Oct. 20, 2023).

25‑48‑101
Short title 25‑48‑102
Definitions 25‑48‑103
Right to request medical aid-in-dying medication 25‑48‑104
Request process - witness requirements 25‑48‑105
Right to rescind request - requirement to offer opportunity to rescind 25‑48‑106
Attending physician responsibilities 25‑48‑107
Consulting physician responsibilities 25‑48‑108
Confirmation that individual is mentally capable - referral to mental health professional 25‑48‑109
Death certificate 25‑48‑110
Informed decision required 25‑48‑111
Medical record documentation requirements - reporting requirements - department compliance reviews - rules 25‑48‑112
Form of written request 25‑48‑113
Standard of care 25‑48‑114
Effect on wills, contracts, and statutes 25‑48‑115
Insurance or annuity policies 25‑48‑116
Immunity for actions in good faith - prohibition against reprisals 25‑48‑117
No duty to prescribe or dispense 25‑48‑118
Health-care facility permissible prohibitions - sanctions if provider violates policy 25‑48‑119
Liabilities 25‑48‑120
Safe disposal of unused medical aid-in-dying medications 25‑48‑121
Actions complying with article not a crime 25‑48‑122
Claims by government entity for costs 25‑48‑123
No effect on advance medical directives

California:	Codes
Colorado:	C.R.S.
Nevada:	NRS
New York:	Laws
Oregon:	OAR, ORS
Texas:	Statutes
World:	Rome Statute, International Dictionary

C.R.S. Section 25-48-112 Form of written request

(1)

C.R.S. Section 25-48-112
Form of written request