POLST Minnesota Form

  • A patient should never be given a POLST form to complete on their own and patients and families should not attempt to complete the form independently. Patients and families are encouraged to speak to their physician or health care provider about having a POLST form completed.
  • A POLST form is invalid without the signature of a physician, advanced practice registered nurse, or a physician assistant.
  • The POLST form is intended to be portable and consistent across the state. POLST Minnesota advises against modifying the form design in any way. No organizational names, logos, bar codes, or other items should be added to the form.
Health care professionals and administrators may access the form here.

Patients and families with questions about the POLST form may refer to this fact sheet: