Can a No CPR request be signed electronically?

Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met and the electronic process meets any applicable healthcare or state rules.

Is clinician attestation required?

Many institutions require a clinician attestation documenting capacity and discussion of alternatives; state law or facility policy may mandate clinician signature for clinical recognition.

Does HIPAA allow eSigning and transmission?

Yes, HIPAA permits electronic handling of protected health information when safeguards are in place. Use a vendor that will sign a Business Associate Agreement (BAA) before transmitting PHI.

What if the patient changes their mind?

A patient may revoke the No CPR request at any time by expressing intent to rescind; document the revocation, obtain signatures as appropriate, and update the medical record immediately.

Are witnesses or notarization required?

Requirements vary by state and facility. Some jurisdictions or legal contexts prefer witnesses or notarization; verify state law and institutional policy before assuming none are needed.

How should the signed form be shared with EMS?

Provide a clear paper copy in the transport packet and, where supported, transmit a certified electronic copy or flag the directive in the EHR for EMS access during transfer.

Electronic Signature
Templates
Healthcare
Healthcare No CPR Request Form

Healthcare No CPR Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

NO CPR REQUEST FORM

This form documents the patient’s informed request that cardiopulmonary resuscitation (CPR) not be attempted in the event of cardiopulmonary arrest. By completing and signing this form, the patient (or authorized surrogate) confirms they understand the consequences of refusing CPR, that the refusal is voluntary, and that the request may be revoked at any time in accordance with the terms below.

Patient Information

Full legal name

Date of birth: Medical record / ID number:

Address

Phone: Emergency contact: Relationship:

Insurance / Billing (optional)

Primary insurer

Policy number

Group number

Subscriber name

Medical History

Current medications Allergies Prior surgeries / serious illnesses Chronic conditions

No CPR Directive (Patient Request)

I, , hereby request that no attempt be made to perform cardiopulmonary resuscitation (CPR) if my heart stops or if I stop breathing. I understand that this request means medical personnel will not attempt chest compressions, electric shock (defibrillation), or emergency intubation for the purpose of resuscitation.

Scope of request (select all that apply):

Apply No CPR directive in all healthcare settings (hospital, clinic, ambulance, long-term care)

Also refuse endotracheal intubation for the purpose of attempted resuscitation

Limited directive: refuse CPR only in inpatient/hospital settings (allow resuscitation efforts in emergency transport)

Other instructions or clarifications

Acknowledgment of Risks and Rights

I acknowledge that refusing CPR may result in death. I have had the opportunity to ask questions, and I understand the nature and likely consequences of this decision. I understand that this request applies to the withholding of CPR only and does not, by itself, withdraw other forms of medical care unless expressly stated above.

I understand that I have the right to revoke this directive at any time, either verbally or in writing, and that revocation will become effective when communicated to my treating healthcare provider. I further understand that healthcare providers may follow standing policies for evaluating and documenting revocation.

Effective date: / / Expiration (if any): / /

HIPAA / Privacy Acknowledgment

I authorize disclosure of relevant health information to providers and personnel responsible for honoring this No CPR request. I acknowledge that my health information may be disclosed to coordinate care and to document this directive in my medical record.

I acknowledge and consent to the disclosure and use of my health information as described above.

Witness / Authorized Representative

If signing by an authorized representative or guardian, complete the following and provide documentation of authority upon request.

Name of representative / witness

Relationship to patient

Phone

Witness statement (optional)

Provider Acknowledgment (for facility use)

The following information documents the clinician review and placement of the No CPR request in the medical record. Completion of these fields does not substitute for any required clinician signature or institutional policy; this area is for administrative documentation.

Reviewing clinician name

Facility / department

License / NPI (optional)

Clinical notes regarding discussion

Legal Certification and Warnings

By signing below, I certify that I am the patient named on this form or the authorized legal representative of the patient, that I have the legal authority to make this healthcare decision, and that I have read and understand the information contained in this form. I understand that refusing CPR may result in permanent injury or death and that this decision is being made voluntarily without coercion.

I understand that healthcare providers are required to follow applicable laws, professional standards, and facility policies when implementing this request. If I believe this request has been ignored or misapplied, I may contact the responsible facility administration for review.

Patient Name:

Relationship (if signing for patient):

Signature:

Date:

What the Healthcare No CPR Request Form Is and When It Applies

The Healthcare No CPR Request Form records a patient or legally authorized representative's instruction that cardiopulmonary resuscitation (CPR) should not be attempted if the patient experiences cardiac or respiratory arrest. It is a focused medical directive used in hospitals, long-term care facilities, hospice, and EMS interactions to communicate a single, time‑specific resuscitation preference. The form is not synonymous with a full advance directive or POLST in every jurisdiction, but when completed and acknowledged correctly it guides clinician decisions during an emergency and reduces ambiguity at the point of care.

Why a Clear No CPR Request Matter in Clinical Settings

A properly completed Healthcare No CPR Request Form provides unambiguous clinical instructions during life‑threatening events, aligns care with patient values, and reduces the risk of unwanted interventions.

Who Typically Completes or Signs This Form

This form is completed by patients with decision‑making capacity or, when necessary, by an authorized surrogate or legal representative.

Patients with capacity who wish to refuse CPR in specified circumstances.
Durable power of attorney for healthcare acting within granted authority.
Clinicians documenting a patient or surrogate decision in the medical record.

Institutions use the completed form to inform care teams, include it in the medical record, and share it with EMS when applicable.

Representative Roles Who Sign or Witness

Patient — Primary Signer

A competent adult patient signs to record their own refusal of CPR. The narrative should explain capacity assessment, the patient's understanding of consequences, and the voluntary nature of the decision to avoid later disputes.

Surrogate or Agent

A legally authorized surrogate signs when the patient lacks capacity. Documentation must cite the legal basis for authority (advance directive, state law, or court order) and record why the surrogate acted in the patient's best interests.

Essential Elements to Include on a Professional Form

A robust Healthcare No CPR Request Form combines clear patient identifiers, a precise refusal statement, confirmation of capacity or authority, signatures, and clinician acknowledgement to be actionable.

Patient ID

Full legal name, date of birth, medical record number, and contact information to ensure correct patient matching across clinical settings.

Refusal Statement

A concise, explicitly worded instruction that CPR should not be attempted, avoiding ambiguous phrases that could be misinterpreted during an emergency.

Decision Authority

Declaration of whether the signer is the patient or an authorized surrogate, and citation of the legal instrument conferring authority if applicable.

Signatures

Printed name, signature, and date for the patient or surrogate and a treating clinician attesting to the conversation and clinical assessment.

Clinician Note

Brief clinician documentation of capacity assessment, alternatives discussed, and any applicable diagnostic context supporting the decision.

Distribution

Fields to record where copies were sent (medical chart, EMS packet, family member) and a checkbox for placement on the electronic health record's problem list.

Step-by-Step: How to Complete the No CPR Request Form

Follow the sequence below to capture a valid, clinically actionable No CPR request that can be shared across care teams and EMS.

01

Confirm Identity: Verify patient identity using two identifiers before completing the form.
02

Assess Capacity: Document the capacity assessment and alternatives discussed with the patient.
03

Record Decision: Enter the refusal statement verbatim and include any clarifying notes.
04

Obtain Signatures: Collect patient/surrogate and clinician signatures plus dates and route copies to records.

How Electronic Completion and Sharing Works in Practice

Electronic completion allows rapid capture, immediate distribution to the EHR, and secure sharing with EMS or receiving facilities when policies permit.

Prepare Form: Upload the PDF or template to the eSigning platform and place required fields.
Assign Signers: Add patient and clinician as signers; include surrogate if appropriate.
Authenticate: Use an appropriate signer authentication method for the clinical context.
Store and Share: Save signed copies in the medical record and send copies to designated recipients.

Sample Digital Workflow Settings for Online Completion

Configure the online workflow to capture signatures, timestamp events, and route copies to health records and authorized contacts.

Field	Configuration
Patient Signature Field	Required; date field auto‑stamps upon signing
Clinician Attestation Field	Required; text area for capacity note
Surrogate Upload	Optional; accept attached POA document
Distribution List	Auto-send signed copy to EHR and EMS contact

Technical Requirements for Secure eCompletion and Transfer

Use a platform that supports secure signatures, audit trails, and HIPAA-level protections when handling protected health information.

Supported Formats: PDF and DOCX accepted for upload
Integrations: Connects to EHRs and cloud storage for archival
Authentication: Email + code or stronger signer verification options

Ensure the chosen platform can produce a tamper-evident signed file and maintain an audit trail suitable for clinical and legal review.

Timing Expectations and Routine Review Intervals

Certain events trigger completion, review, or revalidation of the No CPR request; set clear timelines for review and redistribution.

Effective Immediately:

A signed No CPR request is effective when signed unless the form specifies a future effective date.

Admission Review:

Review the form at each new inpatient admission and confirm if preferences remain current.

Annual Check:

Consider annual confirmation for long‑term care residents or when conditions change.

Transfer Notification:

Transmit the signed directive with the patient on interfacility transfer.

Retention Rule:

Retain signed copies per HIPAA and facility record retention schedules.

Key Processing Stages from Decision to Record

The following milestones outline how a No CPR request moves from decision to accessible clinical record.

01

Patient Decision

Patient or surrogate expresses a clear refusal of CPR documented in conversation.

02

Form Completion

Staff complete the form fields, note capacity, and obtain signatures and dates.

03

Clinical Acknowledgement

Treating clinician documents the discussion and attests to the entry in the medical record.

04

Record Distribution

Signed copy is stored in the EHR and shared with EMS or next care setting as needed.

Common Errors That Make a Form Unclear or Unusable

Using vague language such as 'no heroic measures' instead of explicitly naming CPR leads to uncertain interpretation by responders.
Failing to document capacity or legal authority for a surrogate increases the risk of clinical teams disregarding the directive.
Not including dates or using inconsistent date formats can create confusion about whether the instruction is current or superseded.
Keeping only a single paper copy without routing to the medical record or EMS reduces the chance the directive is available when needed.

Legal and Clinical Risks of an Incorrect or Incomplete Form

Clinical Noncompliance: Unclear forms may lead clinicians to perform unwanted CPR

Invalidation Risk: Missing capacity documentation can render a surrogate's form invalid

Civil Liability: Improperly followed directives can result in malpractice claims

Criminal Exposure: In rare cases, intentional disregard may trigger criminal review

Regulatory Concerns: HIPAA mishandling of records can produce fines or corrective actions

Operational Delay: Ambiguous or inaccessible forms delay emergency decision‑making

Example Scenarios Showing Common Uses

Two practical examples illustrate how the form works in different clinical contexts and why clarity matters.

Case Study 1

An elderly inpatient declines CPR after goals-of-care discussion and signs the form

Clinician documents capacity and alternatives
The signed form was uploaded to the EHR and transmitted with the discharge summary to the primary care provider to guide future decisions.

Case Study 2

A surrogate signs on behalf of an incapacitated patient after presenting a valid durable power of attorney

Staff copy the POA to the chart
EMS personnel accepted the form during a transfer, and the directive prevented unwanted resuscitation in accordance with documented patient preferences.

Comparing eSignature Vendors for Healthcare No CPR Request Workflows

Vendor capabilities and pricing influence compliance and integration choices; the table below summarizes common commercial plans and HIPAA support without including specific date references.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card	No free trial	No free trial	Yes, limited trial	Yes, limited trial
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Yes	Yes	No	No

Frequently Asked Questions About the Healthcare No CPR Request Form

Answers to common questions on validity, signatures, electronic submission, and record handling to reduce confusion during completion and use.

Need help? Contact support

Can a No CPR request be signed electronically?
Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met and the electronic process meets any applicable healthcare or state rules.
Is clinician attestation required?
Many institutions require a clinician attestation documenting capacity and discussion of alternatives; state law or facility policy may mandate clinician signature for clinical recognition.
Does HIPAA allow eSigning and transmission?
Yes, HIPAA permits electronic handling of protected health information when safeguards are in place. Use a vendor that will sign a Business Associate Agreement (BAA) before transmitting PHI.
What if the patient changes their mind?
A patient may revoke the No CPR request at any time by expressing intent to rescind; document the revocation, obtain signatures as appropriate, and update the medical record immediately.
Are witnesses or notarization required?
Requirements vary by state and facility. Some jurisdictions or legal contexts prefer witnesses or notarization; verify state law and institutional policy before assuming none are needed.
How should the signed form be shared with EMS?
Provide a clear paper copy in the transport packet and, where supported, transmit a certified electronic copy or flag the directive in the EHR for EMS access during transfer.

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