3181 SW Sam Jackson Pk Rd BTE234 Portland, OR 97239

Direct Fax to Unit Registration

The Registry’s Emergency Communication Center Specialists can only fax POLST Forms to KNOWN Emergency Department fax numbers.  If you wish to add additional hospital unit fax numbers to the Registry you must fill out the following form.  All fields are mandatory except where otherwise noted.  Fax numbers submitted to the Registry must be renewed anytime the unit’s contact information changes. Please allow 10-14 business days for your request to be processed.  *This is for fax number registration only and not a POLST request form*


Your Name

Your Email

Hospital Name and Address

Unit Name

Fax Number to be Registered

Unit Contact Name

Unit Phone

Optional Message

I certify that I have the authority to make this request, and that the fax number listed, is able to accept a patient’s protected health information