---
title: POLST Form Notarization Request Template - Paperform
description: Professional POLST notarization request form for notary services and healthcare providers. Coordinate medical provider signatures and advance directive documentation with ease.
url: "https://paperform.co/templates/polst-form-notarization-request"
type: static
generatedAt: "2026-03-28T00:44:51.359Z"
---

[← Back to free form templates](/templates/)    ![POLST Form Notarization Request](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/polst-form-notarization-request.png)
    [Preview](https://_preview.paperform.co/ai-template/polst-form-notarization-request) [Use this template for free](/create?ai-template=polst-form-notarization-request)    [Healthcare & Medical Forms](/templates/category/healthcare/)[Legal & Compliance Forms](/templates/category/legal/) [Healthcare](/templates/industry/healthcare/)[Notary Services](/templates/industry/notary/) [Physician](/templates/role/physician/)[Social Worker](/templates/role/social-worker/)[Healthcare Administrator](/templates/role/healthcare-admin/)[Notary Public](/templates/role/notary-public/)     About this free form template
### POLST Form Notarization Request

A POLST (Physician Orders for Life-Sustaining Treatment) form is a critical medical document that translates a patient's end-of-life care wishes into actionable medical orders. When these forms require notarization—whether for legal validity, state requirements, or institutional policies—having a streamlined process is essential for healthcare providers, notary services, and patients alike.

This **POLST Form Notarization Request template** is designed specifically for notary services, healthcare facilities, and independent notaries who coordinate the notarization of advance directive documents. Built with Paperform, this template simplifies the complex process of scheduling, documenting, and completing POLST notarizations while ensuring all required information is collected upfront.

#### Streamlined coordination for sensitive documents

POLST forms involve multiple parties: the patient (or their legal representative), the physician or medical provider who signs the orders, and the notary public who authenticates signatures. This template collects all necessary information in one professional, secure form:

 - Patient and legal representative details
 - Medical provider information and signature coordination
 - Existing advance directive documentation
 - Preferred appointment scheduling
 - Special accommodation requests

The form uses conditional logic to adapt based on whether the patient or their legal representative is submitting the request, ensuring the right information is captured every time.

#### Perfect for notary services and healthcare professionals

Whether you're running an independent notary service, working as a mobile notary specializing in medical documents, or managing notarization services for a healthcare facility, this template helps you:

 - **Collect complete information upfront** to avoid back-and-forth communication
 - **Coordinate with medical providers** who need to sign before notarization
 - **Schedule appointments efficiently** with clear availability preferences
 - **Maintain professionalism** with a branded, secure intake process
 - **Document advance directive status** to ensure continuity of care planning

#### Automate your notarization workflow with Stepper

Once you receive a POLST notarization request, there's often significant coordination required: confirming appointments, sending reminders, coordinating with medical providers, and following up after completion. With [Stepper](https://stepper.io), Paperform's AI-native workflow builder, you can automate these tasks without code.

For example, you could automatically:

 - Send confirmation emails with appointment details and preparation instructions
 - Create calendar events and send reminders to all parties
 - Notify medical providers when their signature is needed
 - Generate follow-up tasks for document delivery
 - Update your CRM or case management system with request details

This level of automation is especially valuable for notary services handling sensitive medical documents where timing, accuracy, and professionalism are paramount.

#### Secure, compliant, and SOC 2 Type II certified

When dealing with medical documents and personal health information, security matters. Paperform is SOC 2 Type II certified and offers enterprise-grade security features, making it a trusted choice for notary services and healthcare-adjacent businesses. While Paperform is not HIPAA compliant, this template is designed for notary service coordination rather than storing protected health information.

#### Get started in minutes

This template is ready to use immediately and can be customized to match your notary service's branding, specific state requirements, or institutional policies. Add your logo, adjust the color scheme, modify questions, and embed it on your website—all without touching a line of code.

Whether you're a mobile notary building your medical document practice or a healthcare facility streamlining your advance directive processes, this POLST Form Notarization Request template gives you a professional, efficient foundation for this important service.
       Built for growing businesses, trusted by bigger ones.   Trusted by 500K+ business owners and creators, and hundreds of millions of respondents.     ![Capterra - 4.8 out of 5](/images/capterra-st.jpg)
 ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg)
 ![G2 - 4.8 out of 5](/images/g2-st.jpg)
  [Try Paperform free now](/register)
## More templates like this
  [![Medical Document Notarization Request Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/medical-document-notarization-request-form.png)

### Medical Document Notarization Request Form

A professional form for requesting notarization services for medical and healthcare documents including HIPAA releases, advance directives, living wills, and healthcare proxy authorizations.](/templates/medical-document-notarization-request-form/)
[![Medical Marijuana Card Application Notarization Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/medical-marijuana-card-application-notarization-form.png)

### Medical Marijuana Card Application Notarization Form

Streamline medical marijuana card applications with physician certification, state registry compliance, and caregiver designation. Secure notarization request form for healthcare providers and notary services.](/templates/medical-marijuana-card-application-notarization-form/)
[![ACC Severe Injury Rehabilitation Plan](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/acc-severe-injury-rehabilitation-plan.png)

### ACC Severe Injury Rehabilitation Plan

A comprehensive rehabilitation planning form for ACC severe injury cases, coordinating multi-disciplinary care teams, tracking long-term recovery goals, and monitoring milestone achievements throughout the rehabilitation journey.](/templates/acc-severe-injury-rehabilitation-plan/)
[![Clinical Negligence Affidavit](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/clinical-negligence-affidavit.png)

### Clinical Negligence Affidavit

A comprehensive sworn statement form for documenting clinical negligence claims, including treatment timeline, breach of standard of care, causation analysis, and injury severity assessment.](/templates/clinical-negligence-affidavit/)
[![CNPJ Pharmaceutical Clinical Study Patient Recruitment Ethics Approval Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/cnpj-pharmaceutical-clinical-study-patient-recruitment-ethics-approval-form.png)

### CNPJ Pharmaceutical Clinical Study Patient Recruitment Ethics Approval Form

Comprehensive patient recruitment form for pharmaceutical clinical studies in Brazil with ethics approval, informed consent, and LGPD-compliant data privacy safeguards.](/templates/cnpj-pharmaceutical-clinical-study-patient-recruitment-ethics-approval-form/)
[![Eating Disorder Residential Treatment Prior Authorization Request](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/eating-disorder-residential-treatment-prior-authorization-request.png)

### Eating Disorder Residential Treatment Prior Authorization Request

Request prior authorization for residential eating disorder treatment with comprehensive psychiatric evaluation, medical stability assessment, and treatment level determination for insurance approval.](/templates/eating-disorder-residential-treatment-prior-authorization-request/)
[![Healthcare Proxy Declaration Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/healthcare-proxy-declaration-form.png)

### Healthcare Proxy Declaration Form

A legally compliant healthcare proxy form for designating a healthcare agent, authorizing medical decisions, granting HIPAA access, and documenting end-of-life care preferences.](/templates/healthcare-proxy-declaration-form/)
[![Heart Transplant Evaluation Prior Authorization Request](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/heart-transplant-evaluation-prior-authorization-request.png)

### Heart Transplant Evaluation Prior Authorization Request

A comprehensive prior authorization form for heart transplant evaluation, capturing advanced heart failure documentation, transplant center referral details, and complete cardiology assessment notes for insurance approval.](/templates/heart-transplant-evaluation-prior-authorization-request/)
[![Hospice Care Prior Authorization Request Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/hospice-care-prior-authorization-request-form.png)

### Hospice Care Prior Authorization Request Form

Submit prior authorization requests for hospice care services including terminal diagnosis documentation, prognosis timeline, and comprehensive palliative care treatment plans for insurance approval.](/templates/hospice-care-prior-authorization-request-form/)
[![Indonesian Clinic Operational License Application Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/indonesian-clinic-operational-license-application-form.png)

### Indonesian Clinic Operational License Application Form

Complete application form for Indonesian clinic operational licensing, including medical practitioner credentials, facility information, equipment inventory, and Ministry of Health compliance requirements.](/templates/indonesian-clinic-operational-license-application-form/)
[![International Adoption Medical Records Authorization Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/international-adoption-medical-records-authorization-form.png)

### International Adoption Medical Records Authorization Form

Comprehensive medical records release form for international adoption, enabling authorized review of orphanage health records, growth tracking, developmental assessments, and post-adoption care planning.](/templates/international-adoption-medical-records-authorization-form/)
[![Medical Advance Directive Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/medical-advance-directive-form.png)

### Medical Advance Directive Form

A comprehensive advance directive form that allows patients to document their healthcare wishes, designate a healthcare proxy, specify end-of-life care preferences including DNR and POLST orders, and register organ donation decisions.](/templates/medical-advance-directive-form/)