The Illinois DNR form is a document that residents of Illinois can use to request information about Department of Natural Resources (DNR) programs and services. The form can be used to request information about hunting, fishing, and other outdoor recreation opportunities in the state. Additionally, the form can be used to request information about environmental protection and conservation initiatives in Illinois. Residents who are interested in learning more about the DNR can use the Illinois DNR form to get started.
You'll find information about the type of form you want to complete in the table. It will show you the length of time you'll need to complete illinois dnr form, exactly what parts you need to fill in, etc.
Question | Answer |
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Form Name | Illinois Dnr Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | illinois dnr form, illinois do not resuscitate, do not resuscitate form, illinois do dnr |
■ HIPAA PERMITS DISCLOSURE OF DNR/POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT ■
IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST
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STATE OF ILLINOIS |
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Illinois Department of Public Health |
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FOR |
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For patients, use of this form is completely voluntary. |
Patient Last Name |
Patient First Name |
MI |
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Follow these orders until changed. These medical orders |
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are based on the patient’s medical condition and prefer- |
Date of Birth (mm/dd/yy) |
Gender q M |
q F |
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ences.Anysectionnotcompleteddoesnotinvalidatethe |
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form and implies initiating all treatment for that section. |
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With significant change of condition new orders may |
Address (street/city/state/ZIPcode) |
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need to be written. |
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A |
CARDIOPULMONARY RESUSCITATION (CPR) If patient has no pulse and is not breathing. |
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Check |
q Attempt Resuscitation/CPR |
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q Do Not Attempt Resuscitation/DNR |
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(Selecting CPR means Full Treatment in Section B is selected) |
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One |
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When not in cardiopulmonary arrest, follow orders B and C. |
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B |
MEDICAL INTERVENTIONS If patient is found with a pulse and/or is breathing. |
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CheckOne |
q Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment |
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described in Selective Treatment and |
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(optional) cardioversion as indicated. Transferto hospital and/or intensive care unit if indicated. |
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qSelective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in
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Request transfer to hospital only if comfort needs cannot be met in current location.
Optional Additional Orders________________________________________________________________________
CMEDICALLYADMINISTERED NUTRITION (if medically indicated) Offer food by mouth, if feasible and as desired. q
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q Trial period of medically administered nutrition, including feeding tubes. |
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One |
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(optional) |
q No medically administered means of nutrition, including feeding tubes. |
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D |
DOCUMENTATION OF DISCUSSION (Check all appropriate boxes below) |
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q Patient |
q Agent under health care power of attorney |
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q Parent of minor |
q Health care surrogate decision maker (See Page 2 for priority list) |
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Signature of Patient or Legal Representative |
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Signature (required) |
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Name (print) |
Date |
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_______________________________________________ |
_________________________________ |
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SignatureofWitnesstoConsent (Witness required for a valid form) |
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I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form and have witnessed the |
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giving of consent by the above person or the above person has acknowledged his/her signature or mark on this form in my presence. |
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Signature (required) |
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Name (print) |
Date |
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_______________________________________________ |
_________________________________ |
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ESignatureofAttendingPractitioner(physician,licensedresident(secondyearorhigher),advancedpracticenurseorphysicianassistant) Mysignaturebelowindicatestothebestofmyknowledgeandbeliefthattheseordersareconsistentwiththepatient’smedicalconditionandpreferences.
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PrintAttending Practitioner Name (required) |
Phone |
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( |
) _________ - ______________ |
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Attending Practitioner Signature (required) |
Date (required) |
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Page 1 |
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_______________________ |
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Form Revision Date January 2015 |
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(Prior form versions are also valid.) |
SENDACOPYOF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPYONANYCOLOR OF PAPER ISACCEPTABLE • 2015
IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST
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■HIPAA PERMITS DISCLOSURE OF DNR/POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
DNR/POLST |
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**THIS SIDE FOR INFORMATIONAL PURPOSES ONLY** |
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TheIllinoisDepartmentofPublicHealth(IDPH)DoNot |
Resuscitate(DNR)/PractitionerOrdersforLifeSustaining |
Treatment |
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Patient Last Name |
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Patient First Name |
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(POLST)isalwaysvoluntary.Thisorderrecordsyourwishesformedicaltreatmentinyourcurrentstateofhealth.Once |
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initial medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may |
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change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can |
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address all the medical treatment decisions that may need to be made. The Power ofAttorney for Health CareAdvance |
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Directive form (POAHC) is recommended for all capable adults, regardless of their health status.APOAHC allows you |
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DNR/POLST |
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to document, in detail, your future health care instructions and name a Legal Representative to speak for you if you are |
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unable to speak for yourself. |
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Advance Directive Information |
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I also have the following advance directives (OPTIONAL) |
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IDPH |
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q Health Care Power ofAttorney |
q Living Will Declaration |
q Mental Health Treatment Preference Declaration |
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Contact Person Name |
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Contact Phone Number |
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Health Care Professional Information |
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DNR/POLSTIDPH |
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Preparer Name |
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Phone Number |
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Preparer Title |
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Date Prepared |
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Completing the IDPH Do Not Resuscitate (DNR)/POLST Form |
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• The completion of a DNR/POLST form is always voluntary, cannot be mandated and may be changed at any time. |
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• ADNR/POLST should reflect current preferences of persons completing the DNR/POLST Form; encourage completion of a POAHC. |
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DNR/POLST |
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• Verbal/phone orders are acceptable with |
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• Use of original form is encouraged. Photocopies and faxes on any color of paper also are legal and valid forms. |
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Reviewing a Do Not Resuscitate (DNR)/POLST Form |
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This DNR/POLST form should be reviewed periodically and if: |
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IDPH |
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• The patient is transferred from one care setting or care level to another, |
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• or there is a substantial change in the patient’s health status, |
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• or the patient’s treatment preferences change, |
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• or the patient’s primary care professional changes. |
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Voiding or revoking a Do Not Resuscitate (DNR)/POLST Form |
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DNR/POLST |
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• Apatient with capacity can void or revoke the form, and/or request alternative treatment. |
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• Changing, modifying or revising a DNR/POLST form requires completion of a new DNR/POLST form. |
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• Draw line through sectionsAthrough E and write “VOID” across page if any DNR/POLST form is replaced or becomes invalid. |
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Beneath the written "VOID" write in the date of change and |
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• If included in an electronic medical record, follow all voiding procedures of facility. |
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IDPH |
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Illinois Health Care Surrogate Act (755 ILCS 40/25) Priority Order |
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1.Patient’s guardian of person |
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5.Adult sibling |
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2.Patient’s spouse or partner of a registered civil union |
6.Adult grandchild |
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3.Adult child |
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7.Aclose friend of the patient |
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4.Parent |
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8.The patient’s guardian of the estate |
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DNR/POLST |
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For more information, visit the IDPH Statement of Illinois law at |
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http://www.idph.state.il.us/public/books/advin.htm |
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HIPAA (HEALTH INSURANCE PORTABILITYAND ACCOUNTABILITYACT of 1996) PERMITS DISCLOSURE |
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IDPH |
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TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT |
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IOCI |
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Page 2 |
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■
IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST ■ IDPH DNR/POLST
■ SENDACOPYOF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPYONANYCOLOR OF PAPER ISACCEPTABLE • 2015 ■