1. The Oregon POLST Registry Information for patients and families

2. What is the Oregon POLST Registry It is a secure electronic record of your POLST orders The Registry allows emergency medical professionals access to your POLST orders if the original POLST form cannot be found The Registry is a back-up system and does not replace your original POLST form

3. How does the Registry work? If, in an emergency, your POLST form cannot be immediately found, emergency medical professionals can call the Registry to obtain your orders

4. How will the Registry get my form? The health care professional who signed your form is required to submit your form to the Registry (unless you opt-out) You can also fax or mail a copy of your form to the Registry: ▫ Registry fax: 503-418-2161 ▫ Oregon POLST Registry 3181 SW Sam Jackson Park Rd CDW-EM Portland, OR 97239

5. What if I don’t want my information in the Registry? If you don’t want your information in the Registry simply check the ‘opt-out’ box on your form If your form was entered into the Registry and you would like it removed, contact us! ▫ Phone: 503-418-4083 ▫ Toll free: 877-367-7657 ▫ E-mail: polstreg@ohsu.edupolstreg@ohsu.edu ▫ Submit a web request: www.orpolstregistry.orgwww.orpolstregistry.org

6. How will I know my form is in the Registry? A confirmation letter will be mailed to you if mailing address information was included with your POLST form. Your confirmation packet will contain a Oregon POLST Registry magnet and set of stickers with your unique Registry ID printed on them ▫ The Registry ID is unique and helps identify your form in the Registry, please refer to this ID any time you call the Registry

7. Confirmation letter To the right is an example of a confirmation letter The letter includes: ▫ Your Registry ID ▫ A synopsis of your section A and section B orders ▫ Information on how to contact the Registry

8. Registry Magnets and Stickers The magnet and stickers are used to alert health care professionals that you have a POLST form on file with the Registry POLST Registry magnets and stickers do not replace the original POLST form

9. Where do I put my magnet and stickers? The Registry magnet (example right) should be placed on your refrigerator It is recommended that you place your stickers: ▫ On your original POLST form ▫ On something you carry with you (ex. your wallet) ▫ The third can be given to your primary care provider

10. Can I get additional magnets and stickers? Yes! The Registry office is happy to provide you with additional magnets, stickers, and even copies of your POLST form To request additional materials: ▫ Phone: 503-418-4083 ▫ Toll free: 877-367-7657 ▫ E-mail: polstreg@ohsu.edupolstreg@ohsu.edu ▫ Submit a web request: www.orpolstregistry.orgwww.orpolstregistry.org

11. Contact the Registry: When your POLST orders change When your personal information changes (address, name, etc.) When you have questions about the Registry 877 -367-7657 We are here to help!

12. How to contact the Registry Phone: 503-418-4083 Toll free: 877-367-7657 Fax: 503-418-2161 E-mail: polstreg@ohsu.edupolstreg@ohsu.edu Website: www.orpolstregistry.orgwww.orpolstregistry.org