What information is required for the patient's Qualified Health Care Practitioner on the POLST form?

• A. License number
• B. Email address
• C. Printed name, signature, and date
• D. Phone number

Answer: (C)

On a POLST form, the essential attestation from the Qualified Health Care Practitioner is their printed name, signature, and date. The printed name makes who completed the form legible, the signature formally authorizes the medical orders, and the date shows when the order was written so caregivers know if it’s current. This combination provides a clear, portable, and legally valid record that can be trusted across care settings.

License numbers, email addresses, or phone numbers aren’t required to validate the order on the form. They may appear in other parts of a patient’s record or contact systems, but they aren’t what establishes the medical orders on the POLST.