New MOLST Forms and Checklists Published by DOH

April 16, 2019


The New York State Department of Health has made changes to the Medical Orders for Life Sustaining Treatment (MOLST) form and Nonhospital Order Not to Resuscitate, DOH Forms 5003 and 3474, respectively. These changes were made to comply with statutory changes, which granted authority to Nurse Practitioners to sign the MOLST and Nonhospital Order Not to Resuscitate. In 2018, the Family Health Care Decisions Act was expanded to allow a Nurse Practitioner who has primary responsibility for the treatment and care of a patient to issue an order concerning life sustaining treatment. All healthcare facilities are encouraged to replace their current supply of DOH Forms 5003, its supporting checklists and DOH 3474 with the most updated versions. Facilities are strongly encouraged to use the bright “Pulsar Pink” paper when replacing their current supply of MOLST forms.

The updated MOLST form and Nonhospital Order Not to Resuscitate Form do not apply to individuals with intellectual or developmental disabilities. For these individuals, a MOLST and Nonhospital DNR must continue to be signed by a physician in accordance with the standards and procedure set forth in Surrogate Court Procedure Act §1750(b).

A copy of DOH Form 5003 and supporting checklists and DOH 3474 from DOH’s website may be found here:


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If you have any questions about this alert, please contact a member of our Discharge Planning, Patient Rights and Elder Law Group or the Garfunkel Wild attorney with whom you regularly work.