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:
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.