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Pennsylvania Out-of-Hospital DNR Order Form

Pennsylvania's Out-of-Hospital Nonresuscitation Act, 20 Pa.C.S. 5481 to 5488, lets an attending physician order EMS providers to withhold CPR if a patient has a cardiac or respiratory arrest outside the hospital. The order can come with a DNR bracelet or necklace. Physicians meet it when a patient with an end-stage or terminal condition, or permanent unconsciousness with a qualifying living will, asks for one.

Who completes it

The attending physician completes item 2A, certifying eligibility and signing last, plus item 2B for a pregnant patient. The patient signs item 3A, or a surrogate or other person with a legal relationship signs item 3B if the patient cannot.

Submitting and payment

How to submit it
Nothing is filed; the order becomes effective when the attending physician signs and stays with the patient, who displays the form or wears the bracelet or necklace for EMS.
Who pays
The official numbered forms, bracelets and necklaces are bought in packs of 50 from the state's designated vendor, with shipping and sales tax added.

Good to know

  • The posted PDF is a sample; official forms must be ordered from the vendor. Prior versions of the form remain valid and are to be honored.
  • EMS withholds CPR, intubation, bag valve mask, defibrillation and resuscitation drugs, but still gives oxygen, suctioning and comfort care unless directed otherwise.
  • For a pregnant patient, item 2B requires that an obstetrician has examined her and both physicians certify specified consequences in the record.
  • The order stays in effect until death or revocation; if the patient obtained it, only the patient may revoke it.

Get the official form

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

Out-of-Hospital Do Not Resuscitate Order

Official pagePDF

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 is eligible for a Pennsylvania out-of-hospital DNR order?

The attending physician must find that the patient has an end-stage medical condition, is in a terminal condition, or is permanently unconscious with a living will that either directs no CPR or authorizes a surrogate to request the order. The patient, surrogate or other person with a legal relationship requests it.

How is a Pennsylvania out-of-hospital DNR revoked?

By destroying or not displaying the order, bracelet and necklace, or by saying so at the time of arrest. If the patient obtained the order, only the patient may revoke it; if a surrogate obtained it, the patient or surrogate may. The patient's mental or physical condition does not limit the right to revoke.