Legislation

* § 2899-k. Form of written request and witness attestation. 1. A
request for medication under this article shall be in substantially the
following form:

REQUEST FOR MEDICATION TO END MY LIFE

I, _________________________________, am an adult who has
decision-making capacity, which means I understand and appreciate the
nature and consequences of health care decisions, including the benefits
and risks of and alternatives to any proposed health care, and to reach
an informed decision and to communicate health care decisions to a
physician.

I have been diagnosed with (insert diagnosis), which my attending
physician has determined is a terminal illness or condition, which has
been medically confirmed by a consulting physician and mental health
professional and will, in the judgment of the physicians and mental
health professional, produce death within six months whether or not
treatment is provided.

I have been fully informed of my diagnosis and prognosis, the nature
of the medication to be prescribed and potential associated risks, the
expected result, and the feasible alternatives and treatment options
including but not limited to palliative care and hospice care.

I request that my attending physician prescribe medication that will
end my life if I choose to take it, and I authorize my attending
physician to contact another physician or any pharmacist about my
request.

INITIAL ONE:

( ) I have informed or intend to inform one or more members of my
family of my decision.

( ) I have decided not to inform any member of my family of my
decision.

( ) I have no family to inform of my decision.

I understand that I have the right to rescind this request or decline
to use the medication at any time.

I understand the importance of this request, and I expect to die if I
take the medication to be 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, of my own volition and without being
coerced, and I accept full responsibility for my actions.
Signed: __________________________
Dated: ___________________________

DECLARATION OF WITNESSES

I declare that the person signing this "Request for Medication to End
My Life":

(a) is personally known to me or has provided proof of identity;

(b) voluntarily signed the "Request for Medication to End My Life" in
my presence or acknowledged to me that the person signed it; and

(c) to the best of my knowledge and belief, has decision-making
capacity and is making the "Request for Medication to End My Life"
voluntarily, of the person's own volition and is not being coerced to
sign the "Request for Medication to End My Life".

I am not the attending physician or consulting physician of the person
signing the "Request for Medication to End My Life" or the mental health
professional who provides a decision-making capacity determination of
the person signing the "Request for Medication to End My Life" at the
time the "Request for Medication to End My Life" was signed.

I further declare under penalty of perjury that the statements made
herein are true and correct and false statements made herein are
punishable.

I further declare that I am not (i) related to the above-named patient
by blood, marriage or adoption; (ii) entitled at the time the patient
signed the "Request for Medication to End My Life" to any portion of the
estate of the patient upon such patient's death under any will or by
operation of law, or otherwise in a position to benefit financially from
the patient's death; (iii) an owner, operator, employee or independent
contractor of a health care facility where the patient is receiving
treatment or is a resident; (iv) a domestic partner of the patient, as
defined in subdivision seven of section twenty-nine hundred
ninety-four-a of the public health law; (v) an agent, as defined in
subdivision five of section twenty-nine hundred eighty of the public
health law, under the patient's health care proxy; or (vi) an agent, as
defined in section 5-1501 of the general obligations law, acting under a
power of attorney for the patient.
Witness 1, Date:
(Printed name)
(Address)
(Telephone number)
Witness 2, Date:
(Printed name)
(Address)
(Telephone number)

2. (a) The "Request for Medication to End My Life" shall be written in
the same language as any conversations, consultations, or interpreted
conversations or consultations between a patient and at least one of the
patient's attending or consulting physicians.

(b) Notwithstanding paragraph (a) of this subdivision, the written
"Request for Medication to End My Life" may be prepared in English even
when the conversations or consultations or interpreted conversations or
consultations were conducted in a language other than English or with
auxiliary aids or hearing, speech or visual aids, if the English
language form includes an attached declaration by the interpreter of the
conversation or consultation, which shall be in substantially the
following form:

INTERPRETER'S DECLARATION

I, (insert name of interpreter), (mark as applicable):

( ) for a patient whose conversations or consultations or interpreted
conversations or consultations were conducted in a language other than
English and the "Request for Medication to End My Life" is in English: I
declare that I am fluent in English and (insert target language). I have
the requisite language and interpreter skills to be able to interpret
effectively, accurately and impartially information shared and
communications between the attending or consulting physician and (name
of patient).

I certify that on (insert date), at approximately (insert time), I
interpreted the communications and information conveyed between the
physician and (name of patient) as accurately and completely to the best
of my knowledge and ability and read the "Request for Medication to End
My Life" to (name of patient) in (insert target language).

(Name of patient) affirmed to me such patient's desire to sign the
"Request for Medication to End My Life" voluntarily, of (name of
patient)'s own volition and without coercion.

() for a patient with a speech, hearing or vision disability: I
declare that I have the requisite language, reading and/or interpreter
skills to communicate with the patient and to be able to read and/or
interpret effectively, accurately and impartially information shared and
communications that occurred on (insert date) between the attending or
consulting physician and (name of patient).

I certify that on (insert date), at approximately (insert time), I
read and/or interpreted the communications and information conveyed
between the physician and (name of patient) impartially and as
accurately and completely to the best of my knowledge and ability and,
where needed for effective communication, read or interpreted the
"Request for Medication to End my Life" to (name of patient).

(Name of patient) affirmed to me such patient's desire to sign the
"Request for Medication to End My Life" voluntarily, of (name of
patient)'s own volition and without coercion.

I further declare under penalty of perjury that (i) the foregoing is
true and correct; (ii) I am not (A) related to (name of patient) by
blood, marriage or adoption; (B) entitled at the time (name of patient)
signed the "Request for Medication to End My Life" to any portion of the
estate of (name of patient) upon such patient's death under any will or
by operation of law, or otherwise in a position to benefit financially
from the patient's death; (C) an owner, operator, employee or
independent contractor of a health care facility where (name of patient)
is receiving treatment or is a resident, except that if I am an employee
or independent contractor at such health care facility, providing
interpreter services is part of my job description at such health care
facility or I have been trained to provide interpreter services and
(name of patient) requested that I provide interpreter services to such
patient for the purposes stated in this Declaration; (D) a domestic
partner of the patient, as defined in subdivision seven of section
twenty-nine hundred ninety-four-a of the public health law; (E) an
agent, as defined in subdivision five of section twenty-nine hundred
eighty of the public health law, under the patient's health care proxy;
or (F) an agent, as defined in section 5-1501 of the general obligations
law, acting under a power of attorney for the patient; and (iii) false
statements made herein are punishable.
Executed at (insert city, county and state) on this (insert day of
month) of (insert month), (insert year).
(Signature of Interpreter)
(Printed name of Interpreter)
(ID # or Agency Name)
(Address of Interpreter)
(Language Spoken by Interpreter)

(c) An interpreter whose services are provided under paragraph (b) of
this subdivision shall not (i) be related to the patient who signs the
"Request for Medication to End My Life" by blood, marriage or adoption;
(ii) be entitled at the time the "Request for Medication to End My Life"
is signed by the patient to any portion of the estate of the patient
upon death under any will or by operation of law, or otherwise in a
position to benefit financially from the patient's death; (iii) be an
owner, operator, employee or independent contractor of a health care
facility where the patient is receiving treatment or is a resident;
provided that an employee or independent contractor whose job
description at the health care facility includes interpreter services or
who is trained to provide interpreter services and who has been
requested by the patient to serve as an interpreter under this article
shall not be prohibited from serving as an interpreter under this
article; (iv) be a domestic partner of the patient, as defined in
subdivision seven of section twenty-nine hundred ninety-four-a of this
chapter; (v) be an agent, as defined in subdivision five of section
twenty-nine hundred eighty of this chapter, under the patient's health
care proxy; or (vi) be an agent, as defined in section 5-1501 of the
general obligations law, acting under a power of attorney for the
patient.

* NB Effective August 5, 2026