Printing Release Form

May 5, 2015 by  
Filed under Healthcare Professionals

Maine POLST Printing Release Form
(Printing Release Form)

The Maine Hospice Council and Center for End-of-Life Care is responsible for administering the Physician Orders for Life-Sustaining Treatment (POLST) program for Maine, on behalf of the Maine POLST Coalition. At this time, we are asking that a healthcare professional, or organization, request permission to use the POLST PDF to print their own forms in-house.

The Maine Hospice Council and Center for End-of-Life Care/Maine POLST Coalition grants such permission to those who can be assured of meeting the following standardized printing requirements:

  • Form is printed on 24lb Lime Green cardstock in black ink on a single page- double sided.
  • Print quality is clear and legible.
  • Confirms with the Maine POLST Program Coordinator ( on an annual basis that the most recent POLST form is being printed.

The purpose of this policy is to ensure that health care professionals later using the form will recognize it in the identical format. Otherwise, there may be concerns by the responder regarding the validity of the orders.

In granting permission to print from the PDF, we request feedback from you as to how this printing process and subsequent form use is working. Please contact us at and provide feedback on the following questions:

  • What metrics do you have installed at your facility to ensure proper tracking of POLST patients/residents?
  • On average, how many forms do you anticipate printing per month (or year)?
  • Is your staff knowledgeable about the POLST paradigm, and can you confirm that the form is being used as intended by the Maine POLST Coalition and the National POLST Pradigm Task Force?

Thank you for your support of the POLST program and your feedback. We look forward to hearing from you and helping to grow your POLST program within the State of Maine.


Kandyce Powell
POLST Program Coordinator
Maine POLST Coalition
Maine Hospice Council and Center for End-of-Life Care

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