Fillable PATIENT ADVOCATE DESIGNATION

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PATIENT ADVOCATE DESIGNATION

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Initials
DCH-3916 (06/15) Page 1 of 7
Michigan Department of Health and Human Services
PATIENT ADVOCATE DESIGNATION
Instructions for Completing DCH-3916
Important Information about a Patient Advocate Designation
You have the right to name a person to make treatment decisions for you if you become so seriously ill or injured that you
cannot make these decisions for yourself. This person is called your "patient advocate." You can select someone to be
your patient advocate by using this "Patient Advocate Designation" form.
This is an important legal document. It can affect decisions about your health care. A separate document, titled
"Frequently Asked Questions about a Patient Advocate Designation," is also available. This document explains what a
patient advocate designation is, why it is important and how to complete the Patient Advocate Designation form (DCH-
3916). A copy of this document can also be found here:
www.michigan.gov/advancedirective
Make sure that you have read this document and ask for help if you have questions. If you do not want a patient
advocate, you do not have to complete this form. However, you may want to keep this page for your records.
I decline to complete this form.
If you choose not to complete this form, you do not have to do anything further. This means that if you do not want to
choose a patient advocate using this form, you do not have to share this form with the Peace of Mind Registry (either by
mail or online).
If you do choose to complete the form, here are a few things to keep in mind:
Witnesses are required.
• Do not sign the form until you have picked out two witnesses. You must have two witnesses with you when you
sign this form.
• There are restrictions on who can be a witness. The "Frequently Asked Questions about a Patient Advocate
Designation" document explains who can be a witness.
You have choices.
• It is a good idea to select a second person, or a "successor patient advocate" in case the first person you choose
is unable to serve for any reason.
• You can write down any wishes you have in this form. Your patient advocate must follow any wishes you write in
this form or that you share with them in another way.
• There are some optional sections on life-support treatment, mental health treatment and organ donation. You can
complete these sections or leave them blank.
You have responsibilities.
• Your patient advocate must also sign an acceptance as part of this form. If you select a "successor patient
advocate" they must also accept by signing this form.
• You, your doctor, and your patient advocate should have a copy of a complete and signed form. You may also
send a copy to the Peace of Mind Registry, or upload it to the Registry's website. The “Frequently Asked
Questions about a Patient Advocate Designation” document explains how to do this.
You have rights.
• You have the right to decide your own health care as long as you are able to do so. Completing this form does
not change that.
• Your patient advocate will only be able to make decisions for you when a doctor and another provider determine
that you cannot participate in your care anymore.
Initials
DCH-3916 (06/15) Page 2 of 7
Michigan Department of Health and Human Services
PATIENT ADVOCATE DESIGNATION
Date of Birth
Last 4 digits of Social Security Number
I,
, am of sound mind and I voluntarily make this
(Print or type your full name)
The person I choose as my patient advocate is:
Name
Telephone Number
Street Address, City, State, and Zip Code
If my first choice cannot serve, I have chosen another person as my second choice or my "successor patient advocate."
The person I choose as my successor patient advocate is:
Name
Telephone Number
Street Address, City, State, and Zip Code
My patient advocate or successor patient advocate must sign this form before he or she can act. I have talked with the
individuals I have chosen as patient advocate and successor patient advocate.
GENERAL POWERS
My patient advocate or successor patient advocate shall have power to make care, custody and medical treatment
decisions for me only if my attending physician and another physician determine I am unable to participate in medical
treatment decisions. For mental health decisions, the second health care professional may be a licensed psychologist.
My religious beliefs prohibit me from having an examination by a doctor, licensed psychologist or other medical
professional. A determination of my inability to make decisions or provide informed consent for mental health
treatment will be made by:
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.
(Print or type your full name)
Street Address, City, State, and Zip Code
Initials
DCH-3916 (06/15) Page 3 of 7
Photocopies of this document can be relied upon as though they were originals.
STATEMENT OF WISHES
My patient advocate has the power to make a wide variety of treatment decisions. In this document, I can write down my
general wishes for the care I would like to receive, like wanting to stay in my home or be treated by a certain doctor or
hospital. I can also list specific treatments that I do or do not want for certain serious illnesses, injuries or disabilities. I
can also state no wishes at all. If I choose not to write down any wishes, this choice shall not be interpreted as limiting the
power of my patient advocate.
I choose not to write any wishes in this document;
OR
My wishes are as follows (you may attach more sheets of paper):
POWER REGARDING LIFE-SUSTAINING TREATMENT
(OPTIONAL)
I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment which would allow
me to die, and I acknowledge such decisions could or would allow my death. My patient advocate can sign a
do-not-resuscitate declaration for me. My patient advocate can refuse food and water administered to me through
tubes.
(Sign your name if you wish to give your patient advocate this authority)
Date
POWER REGARDING ORGAN DONATION
(OPTIONAL)
I expressly authorize my patient advocate to make a gift of the following: (check any that reflect your wishes)
any needed organs or body parts for the purposes of transplantation, therapy, medical research or education
only the following listed organs or body parts for the purposes of transplantation, therapy, medical research
or education: _____________________________________________________________________
my entire body for anatomical study
I wish my gift to go to: _____________________________________________________________
The gift is effective upon my death. Unlike other powers I give to my patient advocate, this power remains after my
death.
(Sign your name if you wish to give your patient advocate this authority)
Date
Initials
DCH-3916 (06/15) Page 4 of 7
POWER REGARDING MENTAL HEALTH TREATMENT
(OPTIONAL)
I expressly authorize my patient advocate to make decisions concerning the following treatments if a physician and
a mental health professional determine I cannot give informed consent for mental health care: (check one or more
consistent with your wishes)
outpatient therapy
my admission as a formal voluntary patient to a hospital to receive inpatient mental health services. I have
the right to give three days’ notice of my intent to leave the hospital
my admission to a hospital to receive inpatient mental health services
psychotropic medication
electro-convulsive therapy (ECT)
I give up my right to have a revocation effective immediately. If I revoke my designation, the revocation is
effective 30 days from the date I communicate my intent to revoke. Even if I choose this option, I still have
the right to give three days’ notice of my intent to leave a hospital if I am a formal voluntary patient.
I have specific wishes about mental health treatment, such as a preferred mental health professional, hospital or
medication. My wishes are as follows (you may attach more sheets of paper):
(Sign your name if you wish to give your patient advocate this authority) Date
SIGN THIS DOCUMENT ON THE FOLLOWING PAGE, ALONG WITH YOUR WITNESSES.
Initials
DCH-3916 (06/15) Page 5 of 7
SIGNATURE
I sign this document voluntarily, and I understand its purpose.
Date
Your Signature
Your Telephone
Your address (Street Address, City, State and Zip Code)
STATEMENT REGARDING WITNESSES
I have chosen two adult witnesses who are not named in my will; who are not my spouse, parent, child, grandchild,
brother, sister or presumptive heir; who are not my physician or my patient advocate; who are not an employee of my life
or health insurance company; who are not an employee of a home for the aged where I reside; who are not an employee
of community mental health program providing me services; and who are not an employee of the health care facility where
I am now.
STATEMENT AND SIGNATURE OF WITNESSES
We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind,
and to be making this designation voluntarily, without duress, fraud or undue influence.
Date
Print Name
Signature of Witness
Witness address (Street Address, City, State and Zip Code)
Date
Print Name
Signature of Witness
Witness address (Street Address, City, State and Zip Code)
FOR YOUR PATIENT ADVOCATE:
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.
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Initials
DCH-3916 (06/15) Page 6 of 7
ACCEPTANCE BY PATIENT ADVOCATE
(1) This designation shall not become effective unless the patient is unable to participate in decisions regarding the
patient’s medical or mental health, as applicable. If this patient advocate designation includes the authority to make an
anatomical gift as described in section 5506, the authority remains exercisable after the patient’s death.
(2) A patient advocate shall not exercise powers concerning the patient's care, custody and medical or mental health
treatment that the patient, if the patient were able to participate in the decision, could not have exercised in his or her own
behalf.
(3) 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.
(4) 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.
(5) 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.
(6) 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 or mental health treatment decisions are presumed to be in the patient's
best interests.
(7) A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to
revoke.
(8) A patient may waive his or her right to revoke the patient advocate designation as to the power to make mental
health treatment decisions, and if such waiver is made, his or her ability to revoke as to certain treatment will be delayed
for 30 days after the patient communicates his or her intent to revoke.
(9) 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.
(10) A patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health
Code, Act No. 368 of the Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.
I, , understand the above conditions and I
(Name of patient advocate)
accept the designation as patient advocate for
, who signed a patient advocate designation for health care on the
(
Name of patient)
following date:
Signed:
Signature of patient advocate
Date
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Initials
DCH-3916 (06/15) Page 7 of 7
I, , understand the above conditions and I
(Name of successor patient advocate)
accept the designation as successor patient advocate for
, who signed a patient advocate designation for health care on the
(Name of patient)
following date:
Signed:
Signature of successor patient advocate
Date
Authority: The MCL 400.105(d)(1)(g)
Completion: Is optional for Healthy Michigan Plan members.
Michigan Department of Health and Human Services is an equal
opportunity employer.
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PATIENT ADVOCATE DESIGNATION

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Completed 6 June 2021

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