In making decisions, my patient advocate shall try to follow my previously expressed wishes, whether those wishes were spoken, written down in another document, or are in this designation.
In making decisions, my patient advocate has authority to consent to or refuse treatment on my behalf, arrange medical and personal services for me, and pay for such services with my funds.
In making decisions, my patient advocate shall have access to any of my medical records to which I have a right, as well as my birth certificate and other legal documents needed to apply for Medicare, Medicaid or other government programs.
I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes.
It is my intent that no one involved in my care shall be liable for honoring my wishes as expressed in this designation, or for following the directions of my patient advocate.
Photocopies of this document can be relied upon as though they were originals.
The role of the patient advocate is defined in Michigan law. As an advocate, it is important that you understand the authority, limitations, rights and responsibilities that apply when you accept this role.
The following list describes some of these rights and responsibilities as described by law. By signing this form, you are accepting these responsibilities. If you have any questions about your duties, refer to the "Frequently Asked Questions about a Patient Advocate Designation" document or ask a lawyer to help you.
I, (Name of Patient Advocate), understand the above conditions and I accept the designation as patient Advocate for (Name of Patient), who signed a patient advocate designation for health care on the following date:
I, (Name of Successor Patient Advocate), understand the above conditions and I accept the designation as patient Advocate for (Name of Patient), who signed a patient advocate designation for health care on the following date: