CA Medical Aid in Dying Written Request Form

This is the first document required to access California's EOL, or Medical Aid in Dying (MAiD) Process. This form will ultimately be filed, along with the physician forms, by SoCal Patient Advocacy LLC to the CA Department of Public Health. You may print this document, fill it out and sign it accordingly, or you may use electronic signatures to complete the form. Once complete, you will send it to our secure email: info@socalpatientadvocacy.com or you may fax the document to us at 866-272-5707