Patient/Family Informed Consent

Castro, Maria
Patient’s Name (Last, M.I., First) ________________________________________________________MR#____________

1. PATIENT SELF-DETERMINATION ACT AND BILL OF RIGHTS

I have received a written statement of my rights as a patient of COMFORTING CARE SERVICES I understand my right
because they have been explained to me and my questions have been answered. I have received written and verbal
information about advance directives. COMFORTING CARE SERVICES policy, applicable state law, the state hotline
number, and other information necessary to make decisions about advance directives and my care in accordance with
the Patient Self-Determination Act of 1990.
2. RELEASE OF INFORMATION
I consent to the release of my personal information by my physician, licensed health care professionals, or facility, and
to allow the disclosure of medical records kept by the above to COMFORTING CARE SERVICES consent to the release of
information by COMFORTING CARE SERVICES or their representative of other health providers involved in my care and
third parties payers in order to assure continued care proper communication of information to my physician(s) and
referral source and proper reimbursement of services.
3. CONSENT TO RECEIVE TREATMENT/CARE
I voluntarily consent to receive care/treatment from COMFORTING CARE SERVICES consistent with a medical
care/treatment plan established by physician and COMFORTING CARE SERVICES interdisciplinary group. I understand
that I will receive from COMFORTING CARE SERVICES palliative focus of hospice care. I understand that if I am in a
condition requiring services not provided by COMFORTING CARE SERVICES my legal representative, or I, or my physician
must arrange for such services COMFORTING CARE SERVICES shall assist in locating such services but shall in no way be
responsible for failure to provide the same, and is hereby release from any and all liability arising from the fact that I am
not provided with such additional care. In the event a health care worker sustains exposure to my blood or body fluids
give permission for my blood to be tested for infectious disease such as HIV and hepatitis. I understand that the exposed
employee will be informed of the result of the test. I understand that I will not be billed for any laboratory fees incurred
in relation to the above circumstances.
4. TYPES OF CARE
The following are the types of care that are provided by COMFORTING CARE SERVICES
a. Routine care – This type of care is provided to any patients who: (1) meets the criteria per Federal and State
guidelines and (2) who resides in a Skilled Nursing Facility (SNF) or in their own home. If the patient has Medi-Cal
coverage, the facility will be reimbursed by the hospice at the Medi-Cal rate.
b. Respite Care – This type of care is provided to offer relief and rest to caregivers who provide care to hospice
patient. Respite Care allows caregivers this relief by providing a trained worker (or in some cases a volunteer) to
be with patient when the caregivers need a break from the care giving duties. This helps caregiver avoid burnout,
stress, and fatigue. Respite care is available for five (5) days per certification period.
c. Continuous Care – This type of care is provided to a patient who: (1) is NOT a resident of SNF, and (2)
experiences a crisis as defined by Hospice rules of Health Care Financing Administration (HCFA). The hospice
agrees to place round-the-clock nursing or aide services in the POS to care for the patient in an
uninterrupted fashion until the patient’s condition dictates a return to hospice care.
d. Short-term Inpatient Care – This type of care is provided to a patient who: (1) is a resident of a SNF,
and (2) experiences acute symptoms which in the judgement of the hospice cannot be effectively
managed. The hospice agrees to provide short-term hospice inpatient care for such a patient in the
SNF provided that the facility has a Registered Nurse (RN) available on the premises 24 hours a day.

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 Patient/Family Informed Consent

5. PAYMENT AUTHORIZATION AND ASSIGNMENT OF BENEFIT

I hereby authorize my insurance company to make payments directly to COMFORTING CARE SERVICES for authorized
service provided. In consideration of COMFORTING CARE SERVICES agreement to forego collection of my account for a
reasonable period of time. I hereby assign to COMFORTING CARE SERVICES or it’s legal representative all of my rights,
including the right to use on my behalf name under policy # ___________ issued by COMFORTING CARE SERVICES to
recover chargers for services rendered by COMFORTING CARE SERVICES This assignment shall not extinguish or diminish
my obligation to pay the full fee to COMFORTING CARE SERVICES for services rendered, but I shall receive credit for all
sums collected pursuant to this agreement. If I enroll in another insurance plan, it is my responsibility to notify
COMFORTING CARE SERVICES otherwise I will be responsible for payment. I understand that my insurance has agreed to
pay _100_% of allowable charges and that my secondary insurance (if applicable) will be billed for _100_%. I understand
that I am responsible for _100_% of allowable charges after my deductible has been met.
6. MEDICARE (PART A&B)
I certify that the information given by me in applying for payment under Title XVIII (Medicare) of the Social Security Act
is correct. I authorize COMFORTING CARE SERVICES to release to the Social Security Administration or its intermediaries
or carriers any information about myself which are needed for Medicare Claims. I request that payment of authorized
benefits be made to COMFORTING CARE SERVICES on my behalf. Services under Medicare aprt A and Medicaid Medical
Assistance are covered at 100% therefore, no co-payment is necessary. I will be notified of any changes in the amount of
charges of the items and services as soon as possible but not later than thirty (30) days from the date that COMFORTING
CARE SERVICES becomes aware of the change.
7. TYPES OF SERVICES
The following are types of services that are provided by COMFORTING CARE SERVICES (a) Skilled nursing services, (b)
Therapy services (Physical Therapy, Occupational Therapy, Speech Therapy), (c) Dietary counseling services, (d) Hospice
physician services, (e) medical social services, (f) Spiritual counseling services, (g) Home health aide and homemaker
services, (h) Pharmaceutical services, and (i) Medical appliance and supplies (DME) services.

8. I acknowledge that I have been given ample opportunity to ask any question I have regarding the Hospice Program of
Care

Mario Castro
PATIENT OR LEGAL GUARDIAN NAME:______________________________________________DATE:________________

SON
SIGNATURE:___________________________________________________________RELATIONSHIP:_________________

WITNESS NAME & SIGNATURE:___________________________________________________DATE:_________________

Patient lacks capacity to sign for self

EXPLAIN IF SOMEONE OTHER THAN PATIENT SIGNS:________________________________________________________

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 PATIENT ACKNOWLEDGEMENT

Castro, Maria
Patient’s Name:____________________________________________MR#___________________Date______________

I have received the following information and have been given the opportunity to ask questions.

IMPORTANT INFORMATION EXPLAINED TO PATIENT/FAMILY/CAREGIVER Explained Left in Home

1. Patient’s freedom of choice in selecting a hospice agency
2. Patient’s condition/plan of care/goals and how related to his/her condition.
3. Patient’s right to participate in the Plan of Care, treatment, and informed of
change
4. Patient/Caregiver is expected to learn and participate in care consistent with
capabilities
5. Disease process, medication regime, and diet
6. Written notice of Patient’s Rights & Responsibilities. Consent, Assignment of
Benefits, Patient Grievance Procedure. Guidelines for Patient care and Emergency
Care.
7. Advance Directives. Has Patient executed an Advance Directive? YES / NO
 Given written materials about right to accept or refuse medical treatment
 Been informed of rights to formulate Advance Directives
 That patient is not required to execute an Advance Directive to receive
medical treatment from this health care facility
 That the terms of any Advance Directives executed will be followed by the
agency and caregivers to the extent permitted by law.
8. Visit plan to include disciplines and frequencies
9. Confidentiality and Disclosure of Clinical Records
10. Basic Home Safety, Infection Control, Disaster Plan
11. Patient liability for payment and right to be informed of any changes
12. Toll-free State Hospice Hot Line number and purpose
13. How to register a complaint with the agency and their right to voice grievance
without fear of reprisal.
14. Discharge Planning.
15. Emergency Disaster Plan Priority Code: Circle One

 Good support system, efficient caregivers in place (Lowest Priority) Category 3

 Support system in place require frequent agency interventions (High Priority) Category 2
 Support systems unreliable and inconsistent and/or on O2, Infusion, or Category 1
ventilator therapy (Highest Priority)
16. Policy for Home use and disposal of controlled substance

Patient/Caregiver Signature:_________________________________________________________Date:______________

Staff Signature/Title:_______________________________________________________________Date:______________

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 HOSPICE MEDICARE/MEDI-CAL BENEFIT ELECTION FORM

As a Medicare Part A or Medi-Cal beneficiary, I hereby elect to receive hospice services provided by COMFORTING CARE
SERVICES My hospice election shall be effective on ___________________________. This election date may be the first
day of hospice care or a later date, but may not be earlier than the date this election statement is signed.

I fully understand the palliative (alleviation of symptoms) rather than curative nature of hospice care, as it relates to the
terminal illness for which I am being admitted. The palliative care provided by COMFORTING CARE SERVICES will be to
relieve symptoms of my terminal illness.

I understand that while this election is in effect, I waive certain Medicare/medi-cal services related to the terminal
condition and I understand that, Medicare/medi-cal will only make payments for care and services related to the
terminal illness to the physician designated below and to COMFORTING CARE SERVICES Services related to the terminal
illness provided by hospitals, home health agencies, nursing homes, or any other company or agency will not be
reimbursed by Medicare/medi-cal unless specifically arranged and authorized by COMFORTING CARE SERVICES I
understand that all care and services not related to the terminal illness will continue to be covered by Medicare/medi-
cal along with hospice benefits. If I reside in a skilled nursing facility, I further understand that payment for routine room
and board charges are not covered by the hospice benefit election and therefore, will not be paid by hospice.

I am aware that I have the right to revoke my election to receive hospice care at any time by signing a revocation form,
and my usual Medicare/Medi-cal benefits will be restored immediately. I further understand that I may, at any time, re-
elect hospice services for any other benefit election if I am eligible to receive.

CHOICE OF ATTENDING PHYSICIAN:

EVISH KAMRAVA, MD
I acknowledge that I have chosen _____________________________________________ as my attending physician.

I acknowledge that I have been given ample opportunity to ask any questions that I have concerning the Hospice
program of care. I acknowledge that I have read and agree to the conditions of the Hospice Benefit Election printed
above.
Castro, Maria
__________________________________________________________________________________________________
Patient Name (Last, First) Medical Record #

5GT8RX2AX51 AJC908435942
__________________________________________________________________________________________________
Medicare ID Number Medi-Cal ID Number

__________________________________________________________________________________________________
Patient or Representative Signature/Relationship to Patient Date

Patient lacks capacity to sign for self

__________________________________________________________________________________________________
If Patient is unable to sign, please state reason

__________________________________________________________________________________________________
Witness Signature Date

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 PATIENT ADVANCE DIRECTIVES STATEMENT

I understand that an Advance directive Includes

 A living will
 Durable power of attorney for health care
 Any other written document executed by the patient, signed and dated that express the
patient’s health care treatment decisions.

I understand that additional information is included in my Hospice folder.

I understand that the Hospice will honor all of my advance directives

o I would like more information regarding advance directives

o I would like to execute one or more advance directives
o I have a living will:
 If YES: Copy obtained? YES / NO
 If NO: describe patient’s wishes:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I have a durable power of attorney: YES / NO

If YES, Name: ___________________________________ Tel: ___________________________________

I have an advance directive: YES / NO

 If YES: Copy obtained? YES / NO

 If NO, describe patient’s wishes:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I have reviewed and understand my Bill of Rights and responsibilities as described above and have been
given written information concerning advance directives and my rights and responsibilities
Mario Castro
_____________________________________________________________________________________
Patient Signature / Responsible Party Print Name Date

Christopher Hendry
_____________________________________________________________________________________
Witness Signature Print Name Date

Castro, Maria
_____________________________________________________________________________________
Patient Name MR#

Doc ID: 18bb142a81315d191de74d8daa04bce0b0966904

 OXYGEN EDUCATION VERIFICATION FORM

Castro, Maria
Patient’s Name: ________________________________________________________________

I hereby verify that I have been instructed on oxygen use/safety and cautioned of the extreme dangers
associated with smoking while oxygen is in use. I fully understand that no one is to smoke while in the same
room or vicinity where the patient is using oxygen.

Patient’s Signature:______________________________________________________Date:________________

______________________________________________________________________Date:_______________
Signature of Patient Representative (Required if the patient is a minor or adult who is unable to sign)

SON
__________________________________________________________________________________________
Representative relationship to patient

Nurse Signature:___________________________________________________________Date:_____________

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 MORTUARY AGREEMENT

It is the policy of COMFORTING CARE SERVICES that information regarding Mortuary Arrangement is
required as a part of the admission process, in the event that Mortuary services are needed, and
family/responsible party is unavailable/unable to be contacted within a four (4) hour period, the Los
Angeles Morgue (323)343-0512 is used as temporary Mortuary Arrangement.

_____________________________________________________________________________________
Patient’s Signature Printed Name Date

Mario Castro
_____________________________________________________________________________________
Responsible Party Signature Printed Name Date

SON
____________________________________________
Relationship to patient

Our social worker and staff are available to assist you in making the arrangements any time

__________________________
Effective Date

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 NOTICE OF PRIVACY PRACTICES
Your rights
The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not
inspect or copy the following records; psychotherapy soles, information compiled in a reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that
prohibits access to protected health information

You have the right to request a restriction of your protected health information. This means you may ask not to use or
disclose any part of your protected health information for the purposes of treatment, payment or health operations.
You may also request that any part of your protected health information not be disclosed to family members or friends
whom may be involved in your care of for notification purposes as described in this Notice of Privacy Practices. Your
request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best
interest to permit use and disclosure of your protected health information, your protected health information will not
be restricted. You then have the right to use another Health care Professional.

You have the right to request to receive confidential communication from us by alternative means or at an alternative
location. You have the right to obtain a paper of this notice from us. Upon request, even if you have agreed to accept
this notice alternatively i.e., electronically.

You may have the right to receive an accounting of certain disclosures we have made, if any, of your protected health
information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the
right to object or withdraw as provided in this notice.

Complaint
You may complain to us or to the Secretary of Health Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you
for filing a complaint.

This notice was published and becomes effective on-or before April 14, 2003.

You have the right to be informed that Computerized Documentation may be applied to your patient medical record.

We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy
practices with respect to protected health information. If you have any objection to this form, please ask to speak with
our HIPPAA Compliance Officer in person or by phone at our main phone number.

Signature below in acknowledgement that you have received this Notice of Privacy Practices:

Mario Castro
__________________________________________________________________________________________________
Print Name Signature Date

Doc ID: 18bb142a81315d191de74d8daa04bce0b0966904

 HIPPA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry
out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health information. “Protected health information” is
information about you, including demographic information, that may identify you and that relates to your past, present
or future physical or mental health or condition and related health care services.

Uses and Disclosures of protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of
our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay
your health care bills, to support the operations of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third party. For
example, we would disclose your protected health information, as necessary, to a home health agency that provides
care to you. For example, your protected health information may be provided to a physician to whom you have been
referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: your protected health information will be used, as needed, to obtain payment for your health care services.
For example, obtaining approval for a hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed your protected health information to support the business
activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities,
employee review activities, training of medical students, licensing, and conducting or arranging for other business
activities. For example, we may disclose your protected health information to medical school students that see patients
at our office.

We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as Required By Law, Public Health issues as required by law, Communicable Disease, Health Oversight,
Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral
Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’
Compensation, Inmates, Required Uses and Disclosures, Under the law, we must make disclosures to you and when
required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance
with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to
object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure indicated in the authorization. ______

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This agreement is entered into, by and between COMFORTING CARE SERVICES and the patient:

This agreement is established to allow the patient to obtain nursing care and other therapeutic services to authorize the
Agency to invoice available payment sources for those services rendered and to permit the release of information from
the patient’s records to insurers and others who may care for him/her in the future.
TREATMENT I consent to receive care and treatment from the Agency
AUTHORIZATION

AGREEMENT TO I authorize the Agency to receive direct payment for services rendered from appropriate
PAY payment sources. I agree to be financially responsible for charges not otherwise covered. In
the event that it becomes necessary to pursue payment through legal proceedings, I agree to
pay for related fees and costs.

ACCURACY OF I certify that information provided by me in applying for payment under Title XVIII or Title XIX
INFORMATION of the Social Security Act is correct.

RELEASE OF I grant permission to the Agency to release information to my insurer and/or other agencies or
INFORMATION individuals who may provide medical or social services to the patient. Additionally, I authorize
the release of medical information to the Agency by any healthcare provider.

PATIENT’S RIGHTS I acknowledge that I have received a copy of the Patient’s Rights & Responsibilities.

NOTICE OF PRIVACY I acknowledge that I have received a copy of the notice of Privacy Practices
PRACTICES

COMPLAINT I have been informed that if I should have any concerns regarding care or treatment, I may
RESOLUTION contact the agency at (818) 781-8111 to report a complaint or grievance. If these efforts do not
resolve my concerns, I am aware that I may also report complaints to the California
Department of Public Health Complaint “Hotline” (800) 228-1019 (CA Department of Public
Health Services, 600 S. Commonwealth Ave. Suite 903. Los Angeles, CA 90005) This number is
available 24 hours/day.

ADVANCED I have been informed verbally and in writing of my rights concerning Advanced Directives
DIRECTIVES

CONSENT TO I authorize the Agency to photograph the patient and to use such photographs for medical
PHOTOGRAPH documentation purposes. This consent is subject to cancellation by written notice from the
undersigned except to that extent that action has been taken.

PHYSICIAN I acknowledge that I have received a copy of the Notice to Consumer where I could file a
complain with the Medical Board of California.

Physical Therapy I acknowledge that I have received a copy of form NTC 12-01 from the Physical Therapy Board
of California
CERTIFICATION I acknowledge that I have read the foregoing, received a copy and am willing to abide by these
agreements.

Castro, Maria
__________________________________________________________________________________________________
Patient Name (Last, First) Patient Signature Date Medical Record #

Doc ID: 18bb142a81315d191de74d8daa04bce0b0966904

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
First follow these orders, then contact Patient Last Name: Date Form Prepared:
Physician/NP/PA. A copy of the signed POLST Castro
form is a legally valid physician order. Any section Patient First Name: Patient Date of Birth:
not completed implies full treatment for that section. Maria 11/05/1937
EMSA #111 B POLST complements an Advance Directive and Patient Middle Name: Medical Record #: (optional)
(Effective 4/1/2017)* is not intended to replace that document.

CARDIOPULMONARY RESUSCITATION (CPR):

A If patient has no pulse and is not breathing.
If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
Check
One  Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)
 Do Not Attempt Resuscitation/DNR (Allow Natural Death)
MEDICAL INTERVENTIONS:
B If patient is found with a pulse and/or is breathing.
 Full Treatment – primary goal of prolonging life by all medically effective means.
Check
One In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation,
advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
 Trial Period of Full Treatment.
 Selective Treatment – goal of treating medical conditions while avoiding burdensome measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and
IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid
intensive care.
 Request transfer to hospital only if comfort needs cannot be met in current location.
 Comfort-Focused Treatment – primary goal of maximizing comfort.
Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual
treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent
with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location.
Additional Orders: ___________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________

ARTIFICIALLY ADMINISTERED NUTRITION:

C  Long-term artificial nutrition, including feeding tubes.
Offer food by mouth if feasible and desired.
Additional Orders: ________________________
Check
One  Trial period of artificial nutrition, including feeding tubes. __________________________________________
 No artificial means of nutrition, including feeding tubes. __________________________________________

INFORMATION AND SIGNATURES:

D Discussed with:  Patient (Patient Has Capacity)  Legally Recognized Decisionmaker
 Advance Directive dated _______, available and reviewed  Health Care Agent if named in Advance Directive:
 Advance Directive not available Name: ________________________________________
 No Advance Directive Phone: _______________________________________
Signature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)
My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s medical condition and preferences.
Print Physician/NP/PA Name: Physician/NP/PA Phone #: Physician/PA License #, NP Cert. #:
Evish Kamrava A125995
Physician/NP/PA Signature: (required) Date:

Signature of Patient or Legally Recognized Decisionmaker

I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding
resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.
Print Name: Relationship: (write self if patient)
Mario Castro SON
Signature: (required) Date:01 / 24 / 2022 Your POLST may be added to a
secure electronic registry to be
Mailing Address (street/city/state/zip): Phone Number: accessible by health providers, as
19860 CITRONIA ST.CHATSWOTH 8182072966 permitted by HIPAA.
SEND FORM WI TH P ATI ENT WHENEVER TR ANSFERRED OR DISCH ARGED
*Form versions with effective dates of 1/1/2009, 4/1/2011,10/1/2014 or 01/01/2016 are also valid

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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Patient Information
Name (last, first, middle): Date of Birth: Gender:
M F
NP/PA’s Supervising Physician Preparer Name (if other than signing Physician/NP/PA)
Name: Name/Title: Phone #:

Additional Contact  None

Name: Relationship to Patient: Phone #:

Directions for Health Care Provider

Completing POLST
• Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers,
and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician,
or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue
appropriate orders that are consistent with the patient’s preferences.
• POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to
ensure consistency, and update forms appropriately to resolve any conflicts.
• POLST must be completed by a health care provider based on patient preferences and medical indications.
• A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance
Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or
person whom the patient’s physician/NP/PA believes best knows what is in the patient’s best interest and will make decisions
in accordance with the patient’s expressed wishes and values to the extent known.
• A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the
decisionmaker’s authority is effective immediately.
• To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under
the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Verbal
orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy.
• If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.
• Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy
should be retained in patient’s medical record, on Ultra Pink paper when possible.
Using POLST
• Any incomplete section of POLST implies full treatment for that section.
Section A:
• If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions
should be used on a patient who has chosen “Do Not Attempt Resuscitation.”
Section B:
• When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,”
should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure
(BiPAP), and bag valve mask (BVM) assisted respirations.
• IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”
• Treatment of dehydration prolongs life. If a patient desires IV fluids, indicate “Selective Treatment” or “Full Treatment.”
• Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.
Reviewing POLST
It is recommended that POLST be reviewed periodically. Review is recommended when:
• The patient is transferred from one care setting or care level to another, or
• There is a substantial change in the patient’s health status, or
• The patient’s treatment preferences change.
Modifying and Voiding POLST
• A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent
to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID”
in large letters, and signing and dating this line.
• A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician/NP/PA, based on
the known desires of the patient or, if unknown, the patient’s best interests.
This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force.
For more information or a copy of the form, visit www.caPOLST.org.
SEND FORM WI TH P ATI ENT WHENEVER TR ANSFERRED OR DISCH ARGED

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 EMERGENCY PLAN

Castro, Maria
Patient Name: _______________________________________________________ MR# ___________________

Diagnosis: __________________________________________________________________________________

Allergies: ___________________________________________________________________________________

In Case of Medical Emergency:

1.) Contact the Hospice: 818-781-8111

2.) The Patient’s physician should be telephoned immediately

EVISH KAMRAVA
Physician Name: ______________________________________________________________________

818-781-8111
Telephone: __________________________________________________________________________

Telephone: __________________________________________________________________________

3.) Close relatives or friends:

ANA ISABEL VASQUEZ

a.) Name: ___________________________________________________________________________
DAUGHTER
Relationship: ________________________________________ 8184486833
Telephone: ____________________

KEYLA VASQUEZ
b.) Name: ___________________________________________________________________________
GRANDDOUGTHER
Relationship: ________________________________________ 8184485352
Telephone: ____________________

ISABEL CERVANTES
c.) Name: ___________________________________________________________________________
DAUGHTER IN LAW
Relationship: ________________________________________Telephone: 8182194567
____________________

Poly-Med Pharmacy
4.) Pharmacy: _____________________________________________ 747-235-3535
Telephone: ____________________

Palmedeq Corp
5.) DME Co.: ______________________________________________ 877-654-0046
Telephone: ____________________

01 / 19 / 2022
Signature/Title: ____________________________________________ Date: _________________________

Doc ID: 18bb142a81315d191de74d8daa04bce0b0966904

 Audit Trail

Title
Comforting Care Consents
File Name
PATIENT FA...PAGE 1.pdf and 11 others
Document ID
18bb142a81315d191de74d8daa04bce0b0966904
Audit Trail Date Format
MM / DD / YYYY
Status Signed

01 / 19 / 2022 Sent for signature to Mario Castro (castrofdxg@gmail.com)

16:15:31 UTC-8 and Christopher Hendry (chris@hendryhelp.com) from
chris@hendryhelp.com
IP: 76.94.86.92

01 / 19 / 2022 Viewed by Christopher Hendry (chris@hendryhelp.com)

16:34:14 UTC-8 IP: 76.94.86.92

01 / 19 / 2022 Signed by Christopher Hendry (chris@hendryhelp.com)

16:34:39 UTC-8 IP: 76.94.86.92

01 / 22 / 2022 Viewed by Mario Castro (castrofdxg@gmail.com)

20:28:56 UTC-8 IP: 172.89.94.226

01 / 24 / 2022 Signed by Mario Castro (castrofdxg@gmail.com)

07:12:58 UTC-8 IP: 172.89.94.226

01 / 24 / 2022 The document has been completed.

07:12:58 UTC-8