"Do-Not-Resuscitate Identification Application - Minor" - Nevada

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

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Download "Do-Not-Resuscitate Identification Application - Minor" - Nevada

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State of Nevada
Do-Not-Resuscitate Identification
Application – Minor
Patient Information (Please Print or Type)
Name:
Last
First
Middle
Address:
Phone #:
Street
City
State
Zip
Birthdate:
Gender:
Male
Female
Parent or Legal Guardian’s Statement
I, the parent or legal guardian of the above named minor, do not wish that life-resuscitating treatment be undertaken
in the event of a cardiac or respiratory arrest of the above named minor. Therefore, I direct Emergency Medical
Services personnel to withhold life-resuscitating treatment in the event of a cardiac or respiratory arrest of the
above named minor.
Parent or Legal Guardian’s Name (print):
Last
First
Middle
Agent’s Address:
Phone #:
Street
City
State
Zip
Parent or Legal Guardian’s Signature:
Date:
Attending Physician’s Statement
As required by Nevada Revised Statutes (NRS) 450B.520(2), I certify that I am the above named 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 and the patient had been issued a Do-Not-Resuscitate order pursuant to NRS 450B.510.
Attending Physician’s Name (Print):
Phone #:
Last
First
Middle
Agent’s Physician’s Signature:
NV License #:
Office use only:
Received:
Issued:
By:
DNR ID #
State of Nevada
Do-Not-Resuscitate Identification
Application – Minor
Patient Information (Please Print or Type)
Name:
Last
First
Middle
Address:
Phone #:
Street
City
State
Zip
Birthdate:
Gender:
Male
Female
Parent or Legal Guardian’s Statement
I, the parent or legal guardian of the above named minor, do not wish that life-resuscitating treatment be undertaken
in the event of a cardiac or respiratory arrest of the above named minor. Therefore, I direct Emergency Medical
Services personnel to withhold life-resuscitating treatment in the event of a cardiac or respiratory arrest of the
above named minor.
Parent or Legal Guardian’s Name (print):
Last
First
Middle
Agent’s Address:
Phone #:
Street
City
State
Zip
Parent or Legal Guardian’s Signature:
Date:
Attending Physician’s Statement
As required by Nevada Revised Statutes (NRS) 450B.520(2), I certify that I am the above named 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 and the patient had been issued a Do-Not-Resuscitate order pursuant to NRS 450B.510.
Attending Physician’s Name (Print):
Phone #:
Last
First
Middle
Agent’s Physician’s Signature:
NV License #:
Office use only:
Received:
Issued:
By:
DNR ID #
In accordance with NRS 450B.525, a parent or
Applicant Instructions
legal guardian of a minor may apply to the health
authority for a DNR identification on behalf of a
1. Provide the information required in the
minor if the minor has been determined by his
‘Patient Information’ section of the
attending physician to be in a terminal condition
application.
and has been issued a DNR pursuant to NRS
450B.510
2. Sign and date the ‘Parent or Legal
Guardian Statement’ section of the
An application submitted must include, without
limitation; certification by the minor’s attending
application.
physician that the minor suffers from a terminal
3. Have the attending physician complete
condition and has been issued a DNR pursuant to
and sign the ‘Attending Physician’s
NRS 450B.510; a statement that the parent or
Statement’ section of the application.
legal guardian of the minor does not wish that life-
State of Nevada
resuscitating treatment be undertaken in the
4. Include a check or money order in the
event of a cardiac or respiratory arrest; the name
Do-Not-Resuscitate
amount of $5, payable to the Division of
of the minor; the name, signature and telephone
number of the minor’s attending physician and the
Public and Behavioral Health, with the
completed application
name, signature and telephone number of the
Identification
minor’s parent or legal guardian.
5. Mail the completed application to:
The parent or legal guardian of the minor may
Application
Emergency Medical Systems
revoke the authorization to withhold life-
4150 Technology Way, Suite 101
resuscitating treatment by removing or destroying,
Carson City, NV 89706
or requesting the removal or destruction of the
Minor
identification or otherwise indicating to the person
(Less than 18 years of age)
that he wishes to have the identification removed
Attending Physician’s Instructions
or destroyed.
Complete the ‘Attending Physician’s
DNR Identification will be a card and document
Statement’ by;
Division of Public and Behavioral Health
issued by the Division of Public and Behavioral
Health signifying the person is a qualified patient
Emergency Medical Systems
1. Provide your name, phone number and
who wishes not to be resuscitated in the event of
NV license number; and
cardiac or respiratory arrest. NRS 450B.410.
4150 Technology Way, Suite 101
2. Sign the ‘Attending Physician’s
Life-resuscitating treatment means
Carson City, NV 89706
Statement’ where indicated.
cardiopulmonary resuscitation (CPR) or any of it
components including chest compressions,
775-687-7590
defibrillation, cardioversion, assisted ventilation,
For additional information please call:
airway intubation and administration of cardiotonic
Division of Public and Behavioral Health
medications.
Emergency Medical Services
775-687-7590
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