048-1 Wyo. Code R. § 1-3

Current through April 27, 2019

Section 1-3 - Provider Orders for Life Sustaining Treatment (POLST) Forms

(a) An individual who wishes to execute a POLST Form must use the form approved by the Department. The form may not be altered in layout or style, including font style and size.

(b) Any person, health care provider or health care facility may obtain a POLST Form from the Department and from the Department's website.

(c) A health care provider, licensed health care facility or EMS provider shall act upon a copy of a POLST Form as if it were original.

(d) The standardized POLST Form shall contain:

• (i) The person's name, date of birth, and gender;

• (ii) Standard protocols, recognized nationally, regarding end-of-life care;

• (iii) Medical condition and patient goals;

• (iv) An area allowing the person, executing the form, to forbid any changes to be made by the surrogate;

• (v) Printed name, address, and telephone number of the Primary Health Care Provider;

• (vi) Signature of Primary Health Care Provider;

• (vii) Signature of person executing the POLST Form; and

• (viii) Dates of signatures;

048-1 Wyo. Code R. § 1-3

Adopted, Eff. 4/12/2016.