Get Dch-3916 - Patient Advocate Designation-final Rev 6-15. Accessible Pdf

Completing the DCH-3916 form, known as the Patient Advocate Designation, is an essential step in allowing a designated individual to make healthcare decisions on your behalf in the event that you are unable to do so. This document provides clear instructions on how to properly fill out each section of the form to ensure that your wishes are accurately represented.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to access the form and open it in your document viewer.
2. Begin filling out the form by providing your full name, address, date of birth, and the last four digits of your Social Security number. Ensure that this information is accurate, as it identifies you on the document.
3. Designate your primary patient advocate by entering their full name, address, and telephone number. Confirm that this individual understands their role and your wishes regarding healthcare.
4. Select a successor patient advocate by providing their full name, address, and telephone number in case your first choice cannot fulfill their responsibilities.
5. Review the general powers section and specify any wishes you have regarding your medical treatment. You may write your general wishes or choose not to articulate specific desires.
6. Complete each optional section regarding life-sustaining treatment, organ donation, and mental health treatment if desired. These sections provide the opportunity to express your specific wishes concerning these critical areas.
7. Sign the document voluntarily after ensuring that both you and the witnesses understand the contents of the form. Be mindful of the responsibilities of the witnesses, confirming they meet the outlined criteria.
8. Have your two witnesses, who are not related to you or your advocate, also sign the document. Their signatures confirm the voluntary nature of the designation and your sound mind.
9. Once all sections are filled, save your changes. You can download and print the completed form for your records and ensure that each relevant party (your doctor, patient advocate, and yourself) has a copy.

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