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Checklists for Patients in a Mental Hygiene Facility

MOLST Instructions and Legal Requirements Checklists for Patients with Mental Illness in a Mental Hygiene Facility

The New York State Office of Mental Health (OMH) is developing checklists setting forth the legal requirements for issuing orders with respect to life-sustaining treatment using the MOLST form in a mental hygiene facility. Once these checklists are approved, the will be posted on this Web page.

PLEASE NOTE
The MOLST form has been approved by the Office of Mental Health (OMH) and the Office for People with Developmental Disabilities (OPWDD) for use as a nonhospital DNR/DNI form for persons with developmental disabilities or persons with mental illness, including persons who are incapable of making their own health care decisions or who have a guardian of the person appointed pursuant to Article 81 of the Mental Hygiene Law or Article 17-A of the Surrogate's Court Procedure Act.

NYS MOLST Form

  •  DOH-5003 MOLST form 
  • Printing the MOLST form on bright "pulsar" pink, heavy stock paper is strongly encouraged.
  • Astrobrights Pulsar Pink 24lb paper is available through Office Depot, Staples, Office Max, and other paper suppliers. 
  • When EMS personnel respond to an emergency call in the community, they are trained to check whether the patient has a pink MOLST form before initiating
    life-sustaining treatment.  They might not notice a MOLST form on plain white paper.
  • However, white MOLST forms and photocopies, faxes, or electronic representations of the original, signed MOLST are legal and valid.
  •   Spanish version of the DOH-5003 MOLST form is for educational purposes ONLY.

Key Resource

For more information on MOLST, view MOLST for Professionals and NYSDOH and MOLST.

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