{"data":{"id":"us-co/c.r.s.-25-48-112","jurisdiction":"us-co","citation":"C.R.S. § 25-48-112","heading":"Form of written request.","body":"(1) A request for medical aid-in-dying medication authorized by this article 48 must be in substantially the following form:\n\nRequest for medication to end my life in a peaceful manner\n\nI, _______________ am an adult of sound mind. I am suffering from _______________, which my attending provider 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.\n\nI request that my attending provider 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 provider to contact any pharmacist about my request.\n\nI understand that I have the right to rescind this request at any time.\n\nI further understand that although most deaths occur within three hours, my death may take longer, and my attending provider 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.\n\nSigned: _______________\n\nDated: ________________\n\nDeclaration of witnesses\n\nWe declare that the individual signing this request:\n\nIs personally known to us or has provided proof of identity;\n\nSigned this request in our presence;\n\nAppears to be of sound mind and not under duress, coercion, or undue influence; and\n\nI am not the attending provider for the individual.\n\n_______________ witness 1/date\n\n_______________ witness 2/date\n\nNote: Of the two witnesses to the written request, at least one must not:\n\nBe 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.\n\nAnd neither the individual's attending or consulting provider 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.","path":["Title 25 - PUBLIC HEALTH AND ENVIRONMENT","Article 48 - End-of-life Options"],"source_url":"https://olls.info/crs/crs2026-title-25.htm","current_through":"Colorado Revised Statutes 2026","vintage":"","retrieved_at":"2026-09-14T18:37:45Z","sha256":"81e36271608725990370e6c321e3f49d4ac48d068984d0e4bc19d815d28025df","source_id":"us-co","stale":false,"prev":"us-co/c.r.s.-25-48-111","next":"us-co/c.r.s.-25-48-113"},"notice":"GroundRules: Original legal text. Not legal advice."}