"Do-Not-Resuscitate Identification Application '" Adult" - Nevada

Do-Not-Resuscitate Identification Application '" Adult is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Do-Not-Resuscitate Identification Application '" Adult" - Nevada

Download PDF

Fill PDF online

Rate (4.5 / 5) 71 votes
Page background image
State of Nevada
Do-Not-Resuscitate Identification
Application – Adult
Patient Information (Please Print or Type)
Name:
Last
First
Middle
Address:
Phone #:
Street
City
State
Zip
Birthdate:
Gender:
Male
Female
A. Patient’s Statement
I, the above named patient, am capable of making an informed decision and do not wish to receive life-resuscitating
treatment in the event of a cardiac or respiratory arrest.
Therefore, I direct Emergency Medical Services
personnel to withhold life-resuscitating treatment. I verify that I have informed each member of my immediate family
whose whereabouts are known to me, and/or my legal guardian or caretaker of my decision to apply for a Do-Not-
Resuscitate Identification.
Patient’s Signature:
Date:
B. Agent’s Statement
I am the above named patient’s agent (with durable power of attorney for healthcare decisions pursuant to NRS 449.786
to 449.900, inclusive). The patient does not wish to receive life-resuscitating treatment in the event of a cardiac or
respiratory arrest. I direct Emergency Medical Services personnel to withhold life-resuscitating treatment in the
event of a cardiac or respiratory arrest.
Agent’s Name (Print):
Last
First
Middle
Agent’s Address:
Phone #:
Street
City
State
Zip
Agent’s Signature:
Date:
Attending Physician’s Statement
As required by Nevada Revised Statutes (NRS) 450B.520(2), I certify that I am the above patient’s attending
physician/physician who has primary responsibility for the treatment and care of the patient and that the patient suffers
from a terminal condition. The patient is capable of making an informed decision or, when he/she was capable of making
an informed decision, he/she executed a written directive that life-resuscitating treatment be withheld under certain
circumstances, or a durable power of attorney for health care decisions pursuant to NRS 449.786 to 449.900, inclusive, or
he/she was issued a Do-Not-Resuscitate order pursuant to NRS 450B.510.
Attending Physician’s Name (Print):
Phone #:
Last
First
Agent’s Physician’s Signature:
NV License #:
Office use only:
Received:
Issued:
By:
DNR ID #
State of Nevada
Do-Not-Resuscitate Identification
Application – Adult
Patient Information (Please Print or Type)
Name:
Last
First
Middle
Address:
Phone #:
Street
City
State
Zip
Birthdate:
Gender:
Male
Female
A. Patient’s Statement
I, the above named patient, am capable of making an informed decision and do not wish to receive life-resuscitating
treatment in the event of a cardiac or respiratory arrest.
Therefore, I direct Emergency Medical Services
personnel to withhold life-resuscitating treatment. I verify that I have informed each member of my immediate family
whose whereabouts are known to me, and/or my legal guardian or caretaker of my decision to apply for a Do-Not-
Resuscitate Identification.
Patient’s Signature:
Date:
B. Agent’s Statement
I am the above named patient’s agent (with durable power of attorney for healthcare decisions pursuant to NRS 449.786
to 449.900, inclusive). The patient does not wish to receive life-resuscitating treatment in the event of a cardiac or
respiratory arrest. I direct Emergency Medical Services personnel to withhold life-resuscitating treatment in the
event of a cardiac or respiratory arrest.
Agent’s Name (Print):
Last
First
Middle
Agent’s Address:
Phone #:
Street
City
State
Zip
Agent’s Signature:
Date:
Attending Physician’s Statement
As required by Nevada Revised Statutes (NRS) 450B.520(2), I certify that I am the above patient’s attending
physician/physician who has primary responsibility for the treatment and care of the patient and that the patient suffers
from a terminal condition. The patient is capable of making an informed decision or, when he/she was capable of making
an informed decision, he/she executed a written directive that life-resuscitating treatment be withheld under certain
circumstances, or a durable power of attorney for health care decisions pursuant to NRS 449.786 to 449.900, inclusive, or
he/she was issued a Do-Not-Resuscitate order pursuant to NRS 450B.510.
Attending Physician’s Name (Print):
Phone #:
Last
First
Agent’s Physician’s Signature:
NV License #:
Office use only:
Received:
Issued:
By:
DNR ID #
Applicant Instructions
The 1997 Legislature enacted Assembly Bill (AB)
29, allowing “qualified patients” to apply for a
1. Provide the information required in the
DNR Identification. AB 29 subsequently was
‘Patient Information’ section of the
codified as Nevada Revised Statute NRS
application.
450B.400 to 450B.590, inclusive. DNR
Identification instructs pre-hospital emergency
2. Sign and date the ‘Patient’s Statement’
medical services personnel to withhold life-
or Agent’s Statement’ section of the
resuscitating treatment in the event of cardiac or
application.
respiratory arrest. EMS personnel will provide
appropriate emergency medical and supportive
3. Have your attending physician complete
care to patients with DNR Identification if the
and sign the ‘Attending Physician’s
patient is not experiencing cardiac or respiratory
Statement’ section of the application.
arrest.
State of Nevada
A “qualified patient” is a patient who has executed
4. Include a check or money order in the
amount of $5, payable to the Division of
a declaration, in accordance with NRS 450B.470,
Do-Not-Resuscitate
Public and Behavioral Health, with the
governing the withholding or withdrawal of life-
completed application
sustaining treatment and who has been
determined by his attending physician to be a
Identification
5. Mail the completed application to:
terminal condition.
Emergency Medical Systems
DNR Identification will be a card and document
Application
4150 Technology Way, Suite 101
issued by the Division of Public and Behavioral
Carson City, NV 89706
Health signifying the person is a qualified patient
who wishes not to be resuscitated in the event of
Adult
cardiac or respiratory arrest. NRS 450B.410.
(18+ years of age)
Attending Physician’s Instructions
Life-resuscitating treatment means
1. Provide your name, phone number and
cardiopulmonary resuscitation (CPR) or any of it
NV license number; and
components including chest compressions,
Division of Public and Behavioral Health
defibrillation, cardioversion, assisted ventilation,
2. Sign the ‘Attending Physician’s
airway intubation and administration of cardiotonic
Emergency Medical Systems
Statement’ where indicated.
medications.
4150 Technology Way, Suite 101
Patients applying for DNR Identification should
For additional information please call:
fully discuss their decision with their family
Carson City, NV 89706
Division of Public and Behavioral Health
members or caretakers. Family members or
775-687-7590
Emergency Medical Systems
caretakers are generally the ones who call EMS
775-687-7590
when the patient needs medical assistance.
Being aware and supportive of the patient’s
wishes in this area allows them to appropriately
advise EMS personnel responding to care for the
patient.
Page of 2