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Michigan Patient Advocate Designation | Form DCH-3916 |
The Michigan patient advocate designation, also known as ‘Form DCH-3916’ respects the US statutes §§ 700.5506 to .5512 and requires 2 witness. Completion of the document by the patient who is usually referred to as the `Principal` permits them to legally choose the medical treatment they will receive should have a medical condition where it becomes impossible for them to make choices at that time. The Michigan patient advocate designation also enables them to select another person, an`Agent`, to facilitate their health care treatment, again in the event of them becoming no longer able to. This form will become invalid should the patient be found to be pregnant. Michigan does not recognize living wills under State law. The ‘Patient Advocate Designation’ is used instead and is much like a medical power of attorney document.
How to Write
Patient Advocate Designation
Important Information
The principal has the option to decline the completion of the form.
- Check the box `I decline to complete this form`.
If The Principal Completes The Form
- Initial the top right corner of each page.
Enter the personal details of the principal.
- Printed name.
- Address.
- Date of birth.
- Last four digits of social security number.
Enter the personal details of the advocate and alternative advocate.
- Name of advocate.
- Address of advocate.
- Telephone number of advocate.
General Powers
If the principal wishes they can nominate an individual to have overall power of attorney due to religious beliefs.
- Check box.
- Enter name of nominee.
Statement Of Witnesses
The principal must choose the type of medical health care they will receive.
- Check box to decline specifying any particular wishes regarding medical health care treatment.
- Check box and enter details of any specific wishes regarding receipt of medical health care treatment.
Power Regarding Life Sustaining Treatment (Optional)
The patient can authorize the agent to withhold or withdraw medical treatment.
- Principal`s signature.
- Date.
Power Regarding Organ Donation (Optional)
The patient can authorize the agent to make a donation.
- Check box to donate any required organs or body parts for transplant, therapy, research or education.
- Check the box and enter details of the specific organs or body parts to be donated for transplant, therapy, research or education.
- Signature of principal.
- Date.
Power Regarding Mental Health Treatment (Optional)
The principal can authorize the agent to make decisions concerning mental health treatment.
- Check box for outpatient therapy.
- Check box to allow admission to hospital for mental health care treatment with the option to leave after 3 days notice.
- Check box to allow admission to hospital for mental health care treatment.
- Check box to allow treatment with psychotropic medicines.
- Check box to allow treatment with electro-convulsive therapy (ECT).
- Enter details of specific wishes regarding mental health care treatment.
- Principal`s signature.
- Date.
Signature
The principal must declare they understand the Patient Advocate Designation
- Date.
- Principal`s signature.
- Principal`s telephone number.
- Principal`s address.
Statement And Signature Of Witnesses
The details of the witnesses must be entered.
- Date.
- Print name.
- Signature.
- Address.
Patient Advocate Declaration
The principal must acknowledge that they understand the Patient Advocate Document.
- Name of advocate.
- Name of patient.
- Signature of advocate.
- Date.
- Name of alternative patient advocate.
- Name of patient.
- Signature of alternative patient advocate.
- Date.
