Patient Advocate Designation (beta for Michigan Residents)

Instructions:

This process generates up to four forms (Patient Advocate Designation, Acceptance by First Patient Advocate, and Acceptance by Second Patient Advocate, and optionally Acceptance by Third Patient Advocate), though you only have to fill in this screen to generate all three forms.

1. Fill in the blanks and click the "generate forms" button. Then print the resulting page from your web browser. You may fill in up to three patient advocates.The second and third advocates are optional.

2. Once the first page prints, click the ">" button near the bottom of the page to generate the first acceptance form. Print that.

3. Then click the ">" button near the bottom of that page to generate the second acceptance form.

4. Repeat the process one more time if you have three advocates.

Print that and you're done!

DISCLAIMER:
MedNotice, LLC provides these forms as a courtesy. The form generator will create a medical durable power of attorney valid under Michigan law when used and signed properly. MedNotice does not give legal advice. By using the form generator, you agree to have the form reviewed by your attorney if you deem it appropriate to do so; and that MedNotice’s liability to you is limited to $5.00 in all cases. The forms are provided “as is” and without any express or implied warranty of any kind including warranties of merchantability or fitness for a particular purpose. IN NO EVENT SHALL MEDNOTICE LLC BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM USE OF OR RELIANCE ON THE INFORMATION PRESENTED ON MEDNOTICE.COM OR FORMS PROVIDED THROUGH MEDNOTICE.COM WHETHER BASED ON WARRANTY, CONTRACT, TORT OR ANY OTHER LEGAL THEORY.
Your full name including first, middle, and last:
Your gender: Male Female
The date you intend to sign this form:
The town or city where you reside:
The city and state where you expect to sign this form:
Your primary (first) patient advocate (include first name, middle initial, and last name):
Your primary patient advocate's home address:
(street, city, state, zip)

The relationship your primary patient advocate is to you (ex: son, daughter, husband, wife): Male Female
Your secondary (second) patient advocate (include first name, middle initial, and last name):
Your secondary patient advocate's home address:
(street, city, state, zip)
The relationship your secondary patient advocate is to you (ex: son, daughter, husband, wife): Male Female
Your third patient advocate (include first name, middle initial, and last name):
Your third patient advocate's home address:
(street, city, state, zip)
The relationship your third patient advocate is to you (ex: son, daughter, husband, wife): Male Female
   
First Witness (full name):
Second Witness (full name):
The date your primary (first) patient advocate intends to sign this form:
The date your secondary (second) patient advocate intends to sign this form:
The date your third (second) patient advocate intends to sign this form: