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MED-PASS:  The Fine Art of Document Design

POLST Form for California - 100/pad


Availability: In stock

Price: $15.40
  • Buy 5-9 for $14.00 each and save 10%
  • Buy 10 or more for $12.90 each and save 17%

POLST (Physician Orders for Life-Sustaining Treatment) medical orders provide greater control over end-of-life care by documenting a person’s preferences regarding specific treatments and key medical decisions. POLST medical orders have already been adopted by the state of California and many other states are developing similar programs.

POLST is different from an Advance Health Care Directive. The POLST Form for California should be completed as part of a discussion with a patient or their health care decision maker and a physician. The completed POLST should be retained by the patient or their health care decision maker and can be revised or voided by the responsible party at any time.

A Ultra Pink POLST for California blank paper version is available for health care providers (LTC, assisted living, home care and hospice) to copy the POLST Form for California onto and meets the California “brightly colored” paper requirement.

Side one of the MED-PASS POLST Form for California documents:

  • A patient’s wishes regarding end-of-life medical interventions such as
    • Cardio-Pulmonary Resuscitation
    • Levels of Comfort Care
    • Artificially Administered Nutrition
  • That the patient or a health care decision maker have discussed the patient’s medical condition and health care preferences and obtains signatures from both parties.


Side two of the MED-PASS POLST Form for California provides directions for:

  • How to complete and use the POLST
  • When the POLST should be reviewed
  • How the patient can modify or void the POLST
  • Updated to reflect the 04/01/2017 recommendations by the California POLST Task Force.
  • Matches the California format
  • Printed on bright pink paper to be clearly identifiable and meet the California “brightly colored” paper requirement
  • Ultra Pink Paper for California version punched 5 holes top and side, available for long-term care, assisted living and home care to use to make copies of the POLST Form for California for their in-house records that comply with the California “brightly colored” paper requirement – see CP111-BPR in Related Products below
Size 8-1/2 x 11
Unit Pads of 100
Other Info Handwritten

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