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Nevada POLST Form: Provider Order for Treatment

Nevada's provider order records CPR, medical intervention and artificial nutrition decisions for patients at risk of a life-threatening event from a life-limiting condition, including advanced frailty. It is meant for people a clinician would not be surprised to see die within a year, and it is honored in all care settings under NRS 449A.500 to 449A.581. Clinicians complete it only after a goals-of-care conversation.

Who completes it

A physician, APRN or PA completes the orders, records whether the patient has decisional capacity in Section D, and signs Section E with license number. The patient, agent, parent of a minor or guardian signs too, or a surrogate signs with the side 2 surrogate details completed.

Submitting and payment

How to submit it
The original goes with the patient when discharged or transferred, and the provider initials side 2 to confirm the patient was told how to submit the signed form to the Nevada Lockbox registry.
Who pays
Official pink forms are free, funded by the Nevada Division of Public and Behavioral Health, and can be picked up or shipped on the orderer's FedEx account.

Good to know

  • The order must be completed on the pink English form; the Spanish version is for reference only and has no signature spaces.
  • Photocopied, faxed or electronic versions are valid as long as the Section E signatures are included; electronically signed documents are valid.
  • Surrogates follow a set order: spouse, majority of adult children, parents, majority of adult siblings, nearest other adult relative, then a caring adult familiar with the patient's values.
  • Form 021523 is current and the previous form 090817 is also valid; Nevada POLST advises checking annually for revisions.

Get the official form

Download the current version from the source each time; forms change without notice.

Nevada Provider Order for Life-Sustaining Treatment (POLST)

Official pagePDFVersión en español

Fill it with Vero

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.

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How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can void a Nevada POLST?

If the patient has decisional capacity, only the patient may void it. If the patient lacks capacity, the agent under a durable power of attorney for health care, a parent of a minor or a legal guardian may revoke it, but a surrogate may only revoke a POLST that the surrogate completed.

Is the Nevada POLST available in Spanish?

A Spanish version exists for reference only. It has no signature spaces for the provider, patient or representative, so providers may print it for Spanish-speaking patients and families to follow along, while the actual orders are completed and signed on the official pink English form.