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Indiana Physician Orders For Scope of Treatment (POST) Form

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Indiana Physician Orders For Scope of Treatment (POST) Form
Indiana Physician Orders For Scope of Treatment (POST) Form
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INDIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (POST)
State Form 55317 (6-13)
Indiana State Department of Health – IC 16-36-6
INSTRUCTIONS: Follow these orders first. Contact treating physician, advanced practice nurse, or physician assistant for further orders if indicated.
Emergency Medical Services (EMS) should contact Medical Control per protocol. These medical orders are based on the patient’s current medical
condition and preferences. Any section not completed does not invalidate the form and implies full treatment for that section. HIPAA permits disclosure
to health care professionals as necessary for treatment. Original form is personal property of the patient.
Patient Last Name
Patient First Name
Middle Initial
Birth date (mm/dd/yyyy)
Medical Record Number
Date prepared (mm/dd/yyyy)
A
Check
One
B
Check
One
C
Check
One
D
Check
One
E
Signature (required by statute)
Print Name (required by statute)
Date (required by statute)
(mm/dd/yyyy)
F
Print Signing Physician Name (required by statute)
Physician Office Telephone Number
(required by statute)
(
)
License Number (required by statute)
Physician Signature (required by statute)
Date (required by statute)
(mm/dd/yyyy)
Office Use Only
Indiana Physician Orders For Scope of Treatment (POST) Form
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