Get Mi Dch-3916 2015-2025

The Michigan Department of Health and Human Services provides the Patient Advocate Designation form, known as MI DCH-3916, to help individuals select a person to make treatment decisions on their behalf when they are unable to do so. This guide offers clear instructions on completing the form online, ensuring that your health care preferences are documented accurately.

Follow the steps to complete the MI DCH-3916 form online.

1. Press the ‘Get Form’ button to retrieve the Patient Advocate Designation form and open it in your online editor.
2. Begin by entering your full name, street address, city, state, zip code, date of birth, and the last four digits of your Social Security Number in the designated fields.
3. Designate a patient advocate by providing their name, telephone number, street address, city, state, and zip code in the specified areas.
4. If applicable, select a successor patient advocate by filling in their name and contact details. This person will step in if your first choice is unable to serve.
5. Review the general powers section where you authorize your patient advocate to make treatment decisions. Ensure you understand the implications of this designation.
6. Consider if you want to write down any specific wishes regarding your care in the statement of wishes section. You can choose not to include any wishes, and this does not limit your advocate's authority.
7. If desired, complete the optional sections regarding life-sustaining treatment, organ donation, or mental health treatment by following the provided prompts.
8. Sign the document, indicating you understand its purpose, along with your contact details.
9. Select two adult witnesses who meet the criteria listed in the document. They must sign the document as witnesses in your presence.
10. Once completed, save your changes, download a copy of the form for your records, and ensure you share it with your patient advocate and any relevant parties.

Take the next step in managing your health care by completing the MI DCH-3916 form online today.