Forms

POLST

The POLST, Physician Orders for Life-Sustaining Treatment, form helps seriously ill or frail patients get the medical treatments they want and avoid medical treatments they do not want. POLST forms are completed by a patient’s healthcare provider (physician, PA or NP) after discussing what is important to them, their diagnosis, what is likely to happen in the future and what their treatment options are. While an advance directive is for anyone that is 18 or older for future care a POLST form is only for those who are seriously ill or frail for current care. 

The POLST form is a portable medical order that follows the patient and helps healthcare providers understand the goals of care whenever or wherever the patient has a medical emergency and can’t speak for him or herself. Meant for individuals with a serious illness or frailty whose healthcare providers would not be surprised if they died within a year or so, the POLST form must be signed by both the patient and healthcare provider.

Arizona POLST form for your provider to complete
(patient copy should be printed on bright pink paper)

Prehospital Medical Care Directive or Do Not Resuscitate (The Orange Form)

Fill out if you do not want to be resuscitated by EMS

The Prehospital Medical Care Directive, or Do Not Resuscitate (DNR) form, informs emergency personnel outside of a hospital setting that if you stop breathing or your heart stops beating, they are not to start cardiopulmonary resuscitation (CPR), nor use equipment, drugs or devices to restart your heart or breathing.

Print this form in color on letter-size (8.5” x 11”) paper and display it in plain sight in your home. You may also print the form in color on wallet-size paper. The form must be signed by you (the patient), a licensed healthcare provider and a witness.

2 ways to request a DNR form:

1. Click here to download the DNR form now (print on orange paper)

2. Call 602- 542-2123 or 800-352-8431 and leave a message

Watch Maricopa County’s Do No Resuscitate Informational Video

Advance Directives

Note, Arizona law is not prescriptive on advance directive forms. Here are a few recommended forms:

Arizona Short Form: Living Will and Healthcare Power of Attorney - English / Spanish

A Living Will is a written statement that expresses your wishes about medical care if you are ever in a terminal condition, a persistent vegetative state or an irreversible coma. You should talk to your doctor about what these terms mean (Office of the Attorney General of Arizona, Life Care Planning Packet).

The Living Will must be signed and witnessed or notarized. It is a standalone document that may also have other advance care planning documents attached to it.

The Durable Healthcare Power of Attorney (second page in the document) is a document that lets you choose another person, called an "agent," to make healthcare decisions if you can no longer make those decisions for yourself. Unless the document includes specific limits, the agent will have broad authority to make any healthcare decision you could normally make for yourself. This could include a decision about whether or not to continue tube feeding. (Office of the Attorney General of Arizona, Life Care Planning Packet, Frequently Asked Questions)

The Health Care Power of Attorney must be signed or notarized, and attached to your Living Will.

Prepare for Your Care - English / Spanish

The Prepare for your care form is a large print advance directive form.