Chapter 33: Additional Resources

Designation of Patient Advocate Form

To my family, doctors, and all concerned with my care.

These instructions express my wishes about my medical care.

Appointment of Patient Advocate

I,________________________________________________________________________________________________________

Appoint the following person to be my Patient Advocate:

Patient Advocate’s Name ____________________________________________________________________________________

Address __________________________________________________________________________________________________

Instructions for Care

1. General Instructions:

My Patient Advocate shall have the authority to make all decisions and to take all actions regarding my care, custody, and medical treatment, including but not limited to the following:

a. Have access to, obtain copies of and authorise release of my medical, mental health and other personal information.

b. Employ and discharge physicians, nurses, therapists, any other health care providers,, and arrange to pay them reasonable compensation.

c. Consent to, refuse or withdraw for me any medical care; diagnostic, surgical, or therapeutic procedure; or other treatment of any type or nature, including life-sustaining treatments.

2. Specific Instructions

My Patient Advocate is to be guided in making medical decisions for me by what I have told him/her about my personal preferences regarding my care. Some of my preferences are recorded below and on the following pages.

A. Specific Instructions Regarding Care I DO want.

_________________________________________________________________________________________________________

B. Specific Instructions Regarding Care I DO NOT want

_________________________________________________________________________________________________________

C. Specific Instructions Regarding Life-Sustaining Treatment

_________________________________________________________________________________________________________

D. Specific Instructions Regarding Anatomical Gifts

My Patient Advocate has the authority, upon or immediately before my death, to make an anatomical gift of all or a part of my body for transplantation needed by another individual; for medical education and research; for anatomical study; or for any other purpose permitted by law. This authority granted to my Patient Advocate shall remain following my death.

E. Any Other Specific Instructions

_________________________________________________________________________________________________________

I am providing these instructions of my free will. I have not been required to give them in order to receive or have care withheld or withdrawn. I am of sound mind.

Signature___________________________________

Date__________________________

Name ______________________________________________________________

Address_____________________________________________________________________

Template Résumé when applying for a job as a Patient Advocate

Name
Address
Telephone Number
Cell Phone Number
E-mail
Web Site

JOB TITLE SOUGHT: Patient-Advocate JOB OBJECTIVE: Job Accomplishments by Organization:

Job Title
Name of Organization
Address
Telephone Number
Supervisor’s Job Title and Name
Dates of Employment
Salary

Career Accomplishments/ Responsibilities:

Education:

School
Degree/Certificate
Extracurricular Activities
Continuing Education

Registrations, Licenses, Certifications:

Special Knowledge, Abilities, Skills:

Professional Organisations:

Publications:

Awards/Honours:

1.
2.
3.

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