Patient & Family Advisor Application

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Thank you for your interest in becoming a Patient and Family Advisor. Please complete the following information.

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Section 1: Applicant Information

Daytime phone
Evening phone
Cell phone
Email

Section 2: Applicant Background

Patient
Family member

Applicant Interest

     
Focus group
Provide feedback in a group format with other patients/family members
Serve on a committee
Bring the patient/family perspective to committee meetings
Story sharing
Share your healthcare experience with care providers and other patients
Short term projects
Be a partner in making improvements to specific healthcare services
Patient and Family Advisory Council
Attend monthly meetings to review programs and services

Authorization

After your application is received and reviewed, the Director of Patient and Family Centered Care will contact you to further discuss your interest and to schedule an interview if your experience fits our needs.

Call 877-RES-INFO for Nurse Advice, Doctor Referrals or Class Registration Monday - Friday 8 am to 8 pm • Weekends 8 am to 4pm

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