Reminders:

  • POLST completion is always voluntary for patient.
  • POLST is not just a check-box form.  POLST should be completed as part of a rich conversation between a patient and their health care provider regarding the patient’s current medical condition, personal values and goals of treatment. This helps ensure that patients have the information they need to make informed choices.
  • In January 2016, the California POLST form was revised to allow nurse practitioners and physician assistants – under the supervision of a physician and within their scope of practice – to sign POLST forms and make them actionable medical orders.
  • Everyone is encouraged to use the most current POLST form. However, POLST completed using previous versions of the form are still considered valid.
  • It is recommended that POLST be copied on bright pink paper to help ensure that the document stands out and is followed. However, POLST on any color paper is valid.
  • Copies and faxes of POLST are valid.  The original, signed POLST travels with the patient.
  • Whenever possible, ensure the Advance Directive (if one exists) and POLST form are consistent with each other.

Downloadable POLST Forms

English PDF

Translations of the 2016 POLST form:

IMPORTANT: Translations are for reference only, and are provided to assist healthcare providers in explaining the form to patients and loved ones. The POLST form must be completed and signed in English so that emergency medical personnel and other healthcare providers can easily read and follow the orders.

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Consumer-Focused Coversheets

Residential Care Facilities (RCFE)

RCFE cover sheet for POLST PDF

This cover sheet should be attached to POLST forms distributed at Residential Care Facilities for the Elderly (RCFE).

POLST is a tool for medical decision making, and the form should always be introduced in the context of a conversation with a medical professional.


Skilled Nursing Facilities (SNF)

SNF cover sheet for POLST PDF

This cover sheet should be attached to POLST forms distributed at Skilled Nursing Facilities (SNF).

POLST is a tool for medical decision making, and the form should always be introduced in the context of a coversation with a medical professional.