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Patient Name: _
Date of Birth (mm/dd/yyyy): _
SIGNATURE OF PATIENT OR LEGALLY APPOINTED REPRESENTATIVE: In order for the POST form to be
effective, the patient or legally appointed representative must sign and date the form below.
E
SIGNATURE OF PATIENT OR LEGALLY APPOINTED REPRESENTATIVE
My signature below indicates that my physician or physician’s designee discussed with me the above orders and
the selected orders correctly represent my wishes.
Signature (required by statute) Print Name (required by statute)
Date (required by statute)
(mm/dd/yyyy)
F
CONTACT INFORMATION FOR LEGALLY APPOINTED REPRESENTATIVE IN SECTION E (IF APPLICABLE):
If the signature above is other than patient’s, add contact information for the representative.
Relationship of representative identified in
Section E if patient does not have capacity
(required by statute)
Address (number and street, city, state, and ZIP code)
Telephone Number
PHYSICIAN ORDER:
A POST form may be executed only by an individual’s treating physician, advanced practice registered nurse, or physician
assistant, and only if:
(1) the treating physician, advanced practice registered nurse, or physician assistant has determined that:
(A) the individual is a qualified person; and
(B) the medical orders contained in the individual’s POST form are reasonable and medically appropriate for the
individual; and
(2) the qualified person or representative has signed and dated the POST form
A qualified person is an individual who has at least one (1) of the following:
(1) An advanced chronic progressive illness.
(2) An advanced chronic progressive frailty.
(3) A condition caused by injury, disease, or illness from which, to a reasonable degree of medical certainty:
(A) there can be no recovery; and
(B) death will occur from the condition within a short period without the provision of life prolonging procures.
(4) A medical condition that, if the person were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful
or within a short period the person would experience repeated cardiac or pulmonary failure resulting in death.
G
DOCUMENTATION OF DISCUSSION: Orders discussed with (check one):
Patient (patient has capacity) Health Care Representative Legal Guardian
Parent of Minor Health Care Power of Attorne
H
SIGNATURE OF TREATING PHYSICIAN / ADVANCED PRACTICE REGISTERED NURSE / PHYSICIAN ASSISTANT
My signature below indicates that I or my designee have discussed with the patient or patient’s representative the
patient’s goals and treatment options available to the patient based on the patient’s health. My signature below
indicates to the best of my knowledge that these orders are consistent with the patient’s current medical condition
and preferences.
Signature of Treating Physician / APRN / PA
(required by statute)
Print Treating Physician / APRN / PA Name
(required by statute)
Date (required by statute)
(mm/dd/yyyy)
Physician / APRN / PA office telephone number
(required by statute)
Physician / APRN / PA License Number
(required by statute)
Health Care Professional preparing form
if other than the physician / APRN / PA
I
APPOINTMENT OF HEALTH CARE REPRESENTATIVE: As patient you have the option to appoint an individual to
serve as your health care representative pursuant to IC 16-36-1-7. You are not required to designate a health
care representative for this POST form to be effective. You are encouraged to consult with your attorney or other
qualified individual about advance directives that are available to you. Forms and additional information about
advance directives may be found on the ISDH web site at http://www.in.gov/isdh/25880.htm.
