■ HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT • VERSION REVISED SEPTEMBER 2022 ■
**THIS PAGE IS OPTIONAL – use for informational purposes**
Use of the Illinois Department of Public Health (IDPH) Practitioner Orders for Life-Sustaining Treatment (POLST) Form
is always voluntary. This order records a patient’s wishes for medical treatment in their current state of health. The patient or patient
representative and a health care provider should reassess and discuss interventions regularly to ensure treatments are meeting patient’s
care goals. This form can be changed to reflect new wishes at any time.
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 a person to document, in
detail, future health care instructions and name a Legal Representative to speak on their behalf if they are unable to speak for
themselves.
Advance Directives available for patient at time of this form completion
Power of Attorney for Health Care
Living Will Declaration
Declaration for Mental Health Treatment
Health Care Professional Information
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 consent by the patient or legal representative are acceptable.
• Verbal/phone orders are acceptable with follow-up signature by authorized practitioner in accordance with facility/community policy.
• Use of the original form is encouraged. Digital copies and photocopies, including faxes, on ANY COLOR paper are legal and valid.
• Forms with eSignatures are legal and valid.
• A qualified health care practitioner may be licensed in Illinois or the state where the patient is being treated.
Reviewing a POLST Form
This POLST form should be reviewed periodically and in light of the patient’s ongoing needs and desires. These include:
• transfers from one care setting or care level to another;
• changes in the patient’s health status or use of implantable devices (e.g., ICDs/cerebral stimulators);
• the patient’s ongoing treatment and preferences; and
• a change in the patient’s primary care professional.
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
2. Patient’s spouse or partner of a registered civil union
7. A close friend of the patient
8. The patient’s guardian of the estate
9. The patient’s temporary custodian appointed under subsection
(2) of Section 2-10 of the Juvenile Court Act of 1987 if the court has
entered an order granting such authority pursuant to subsection
(12) of Section 2-10 of the Juvenile Court Act of 1987.
For more information, visit the IDPH Statement of Illinois law at http://dph.illinois.gov/topics-services/health-care-regulation/nursing-
homes/advance-directives
HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996)
PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT