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Minnesota POLST Form: Provider Orders (MMA)

This form turns a seriously ill or frail Minnesotan's choices on CPR and medical treatment into orders that follow the patient across settings. The Minnesota Medical Association developed the form in 2010 and revised it in February 2017, and Minnesota has no POLST statute. Nurses or social workers often hold the conversation, but the form becomes a medical order only when a licensed provider signs it.

Who completes it

An MD, DO, PA or APRN signs the provider block with printed name, license type, signature and date, all marked required. The patient or surrogate signature is strongly recommended, and the preparer's name, title, phone and date go on page 2.

Submitting and payment

How to submit it
Nothing is filed with the state; the form is sent with the patient whenever transferred or discharged, and faxed, photocopied or electronic versions are valid.

Good to know

  • Any section left blank implies full treatment for that section, and choosing Attempt Resuscitation in Section A requires Full Treatment in Section B.
  • Page 2 Section E holds optional preferences on tube feeding, IV or oral antibiotics and other treatments such as dialysis or duration of intubation.
  • Verbal or phone orders are acceptable with a follow-up signature by the physician, APRN or PA under facility or community policy.
  • To void it, draw a line through Sections A to E and write VOID. Earlier Minnesota POLST versions remain valid.

Get the official form

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

POLST Minnesota (Provider Orders for Life-Sustaining Treatment)

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.

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Frequently asked questions

Who can sign a Minnesota POLST?

A licensed provider: an MD, DO, PA or APRN. The MMA notes that nurses or social workers often lead the POLST discussion, but the provider's signature is what makes it a medical order. The patient or surrogate signature is strongly recommended, and its absence does not cancel the orders.

When should a Minnesota POLST be reviewed?

Periodically, and when the patient moves from one care setting or level to another, has a substantial change in health, changes treatment preferences or changes primary medical care provider. Completing a POLST is always voluntary, and it does not replace a Health Care Directive, which the form encourages all capable adults to complete.