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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: |
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| Your
gender: |
Male
Female |
| The
date you intend to sign this form: |
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| 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: |
|
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