Idph Uniform Practitioner Order For Life-Sustaining Treatment (Polst) Form Page 2

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HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
**THIS SIDE FOR INFORMATIONAL PURPOSES ONLY**
Patient Last Name
Patient First Name
MI
Use of the Illinois Department of Public Health (IDPH) Practitioner Orders for Life-Sustaining Treatment (POLST) Form
is always voluntary. This order records your wishes for medical treatment in your current state of health. Once initial
medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may
change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can
address all the medical treatment decisions that may need to be made. The Power of Attorney for Health Care Advance
Directive (POAHC) is recommended for all capable adults, regardless of their health status. A POAHC allows you to
document, in detail, your future health care instructions and name a Legal Representative to speak for you if you are
unable to speak for yourself.
Advance Directive Information
I also have the following advance directives (OPTIONAL)
q Health Care Power of Attorney
q Living Will Declaration
q Mental Health Treatment Preference Declaration
Contact Person Name
Contact Phone Number
Health Care Professional Information
Preparer Name
Phone Number
Preparer Title
Date Prepared
Completing the IDPH POLST Form
• The completion of a POLST form is always voluntary, cannot be mandated and may be changed at any time.
• A POLST should reflect current preferences of persons completing the POLST Form; encourage completion of a POAHC.
• Verbal/phone orders are acceptable with follow-up signature by authorized practitioner in accordance with facility/community policy.
• Use of original form is encouraged. Photocopies and faxes on any color of paper also are legal and valid forms.
Reviewing a POLST Form
This POLST form should be reviewed periodically and if:
• The patient is transferred from one care setting or care level to another, or
• or there is a substantial change in the patient’s health status, or
• or the patient’s treatment preferences change, or
• or the patient’s primary care professional changes.
Voiding or revoking a POLST Form
• A patient with capacity can void or revoke the form, and/or request alternative treatment.
• Changing, modifying or revising a POLST form requires completion of a new POLST form.
• Draw line through sections A through E and write “VOID” across page if any POLST form is replaced or becomes invalid.
Beneath the written "VOID" write in the date of change and re-sign.
• If included in an electronic medical record, follow all voiding procedures of facility.
Illinois Health Care Surrogate Act (755 ILCS 40/25) Priority Order
1. Patient’s guardian of person
5. Adult sibling
2. Patient’s spouse or partner of a registered civil union
6. Adult grandchild
3. Adult child
7. A close friend of the patient
4. Parent
8. The patient’s guardian of the estate
For more information, visit the IDPH Statement of Illinois law at
HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996) PERMITS DISCLOSURE
TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Page 2
IOCI 16-425
SEND A COPY OF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPY ON ANY COLOR OF PAPER IS ACCEPTABLE • 2016

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