Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form Page 4
ADVERTISEMENT
1
2
3
4Acceptance of Patient Advocate
The Patient Advocate and any successor Patient Advocate must sign this Acceptance before he/she may act as Patient Advocate.
I agree to be the Patient Advocate for _________________________________________ (called “Patient” in the rest of this
document). I accept the Patient’s designation of me as Patient Advocate. I understand and agree to take reasonable steps to
follow the desires and instructions of the Patient as indicated in the Designation of Patient Advocate, in other written instructions
of the Patient and as we have discussed verbally.
I also understand and agree that:
a. This designation shall not become effective unless the Patient is unable to participate in medical or mental health treatment decisions.
b. A Patient Advocate shall not exercise powers concerning the patient’s care, custody and medical treatment that the
Patient, if the Patient were able to participate in the decision, could not have exercised on his or her own behalf.
c. This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a ‘Patient who
is pregnant that would result in the pregnant Patient’s death.
d. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a Patient to die only if
the patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a
decision and that the Patient acknowledges that such a decision could or would allow the Patient’s death.
e. A Patient Advocate shall not receive compensation for the performance of his or her authority, rights and responsibilities,
but a Patient Advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her
authority, rights and responsibilities.
f.
A Patient Advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the Patient
and shall act consistent with the Patient’s best interests. The known desires of the Patient expressed or evidenced while
the Patient is able to participate in medical treatment decisions are presumed to be in the Patient’s best interests.
These restrictions are required by the Patient Advocate Act of 1990, P.A. No. 312 (MCLA 700.496)
g. A Patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.
h. A Patient Advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to
communicate an intent to revoke.
i.
A Patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act
No. 368 or the Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.
If I am unavailable to act after reasonable effort to contact me, I delegate my authority to the persons the Patient has designated as
Successor Patient Advocate in the order designated. The Successor Patient Advocate is authorized to act until I become available to act.
PATIENT ADVOCATE
Sign Name___________________________________________________________________________________________________
Name ______________________________________________________________________________________________________
t
ype or print
Address_____________________________________________________________________________________________________
Home Phone ____________________________________
Work Phone ___________________________________________
Successor PATIENT ADVOCATE
Sign Name __________________________________________________________________________________________________
Name ______________________________________________________________________________________________________
type or print
Address ____________________________________________________________________________________________________
Home Phone ____________________________________
Work Phone ___________________________________________
Successor PATIENT ADVOCATE
Sign Name___________________________________________________________________________________________________
Name ______________________________________________________________________________________________________
t
ype or print
Address ____________________________________________________________________________________________________
Home Phone ____________________________________
Work Phone ___________________________________________
- 4 -
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical