New York Do Not Resuscitate (DNR) Order FormNew York Do Not Resuscitate (DNR) Order FormNew York Do Not Resuscitate (DNR) Order Form
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Medical Orders for Life­Sustaining Treatment (MOLST)

NEW YORK STATE DEPARTMENT OF HEALTH

THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.

LAST NAME/FIRST NAME/MIDDLE INITIAL OF PATIENT

ADDRESS

CITY/STATE/ZIP

Male

Female
eMOLST NUMBER (THIS IS NOT AN eMOLST FORM)

DATE OF BIRTH (MM/DD/YYYY)

Do­Not­Resuscitate (DNR) and Other Life­Sustaining Treatment (LST)
This is a medical order form that tells others the patient’s wishes for life­sustaining treatment. A health care professional must complete or change the MOLST
form, based on the patient’s current medical condition, values, wishes and MOLST Instructions. If the patient is unable to make medical decisions, the orders
should reflect patient wishes, as best understood by the health care agent or surrogate. A physician must sign the MOLST form. All health care professionals must
follow these medical orders as the patient moves from one location to another, unless a phy