Please rate Polst Printable Form Emsa #111 B (Effective 4-1-2017
Signatures are required from the physician, NP or PA and from the patient or legally recognized decisionmaker.
Signed by: a physician, or a nurse practitioner or physician assistant acting under the supervision of a physician and within the scope of practice authorized by law.
Decisionmaker: a legally recognized decisionmaker may execute it only if the patient lacks capacity or has designated that the authority is effective immediately.
Section: any section not completed implies full treatment for that section.
Copies: photocopies and FAXes of signed POLST forms are legal and valid.
Valid versions: form versions with effective dates of 1/1/2009, 4/1/2011, 10/1/2014 or 01/01/2016 are also valid.
| Question | Answer |
|---|---|
| Form Name | EMSA #111 B |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 51 |
| Avg. time to fill out | 9 min |
| Edition | Effective 4/1/2017 |
| Transfer or discharge | Send the form with the patient whenever transferred or discharged |
| Copy | A copy should be retained in patient's medical record, on Ultra Pink paper when possible |
| Other names | EMSA #111 B, EMSA 111B, EMSA-111, POLST, POLST form, California POLST, Physician Orders for Life-Sustaining Treatment |
| Official source | EMSA #111 B (Effective 4/1/2017) |
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Please rate Polst Printable Form Emsa #111 B (Effective 4-1-2017
