The National POLST Collaborative publishes this model portable medical order for CPR, initial treatment, additional orders and medically assisted nutrition, which states may adopt as their official POLST form. Some states add their own information on page 2, a border or a paper color. Clinicians meet it in states that have adopted it, such as Maine and Virginia, for patients at risk from a serious life-limiting condition or advanced frailty.
A licensed health care provider authorized by state law to sign POLST forms, typically a physician, NP or PA, completes the orders and signs Section F after a conversation with the patient or surrogate. The patient or surrogate signs Section E.
Download the current version from the source each time; forms change without notice.
National POLST Form: A Portable Medical Order
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The form carries a notice that it can only be used in states that have adopted it, and polst.org says only state-developed and approved forms are valid. Check the state POLST program directory to see whether your state uses the national form, and order official forms through that program.
No. It should be reviewed when the patient moves between care settings or levels, has a substantial change in health, changes primary provider or changes treatment preferences or goals. The most recently completed valid POLST supersedes earlier ones, and changes require voiding the form and completing a new one.