HHC Patient & Family Advisor Member

Welcome! The Role of the Patient and Family Advisor is to provide hospital administrators, physicians, and staff with suggestions and feedback relative to issues impacting patients and their families. The Patient and Family Advisory Councils meet monthly (10) ten times per year, for a term of 1-3 years.

If you are interested in serving on one of our Patient and Family Advisory Councils, please complete the fields below and submit this form. After review of your information, a staff member will contact you to discuss your interest.

***Please create your user name and a secure password***

Secure passwords should contain a minimum of 5 characters with any combination of letters and/or numbers.

Volunteers are responsible for the safe-keeping of their passwords.

New User Details

User ID

User ID (verify)

Password

Password (verify)

* I am over the age of 18 and not in High School

CONTACT INFORMATION

* First name

* Family/last name

* Address 1

Address 2

* City

* State

* Zip/postal

* Preferred Phone

This is my...

Alternate phone

Alternate phone is my...

* E-mail

Preferred Contact Method

Best time to reach you

ABOUT YOU

Your Age

* Occupation/Job Title

Highest grade completed

Race

Race Other

Languages Spoken

Other Languages spoken

YOUR IMPACT AS AN ADVISOR

I am....

In the last 2 years what care and/or services have you or a family member received?

Other services not listed above

* Why would you like to serve as a Patient/Family Advisor?

* Please tell us about any previous experience as an advisor, volunteer or committee member.

* What are some specific suggestions you currently have to improve the healthcare experience?

I am interested in the folllowing (check all that apply)

CONDITIONS OF PATIENT & FAMILY ADVISOR ROLE (Please read before acknowledging)

 In order to participate as a Patient Family Advisor you must meet our requirements which include a criminal background check, HIPAA training, immunization records and confidentiality agreement. By submitting this application you are certifying that the statements and information contained are true and correct. You understand and acknowledge that you will not be paid for your services as a volunteer member of the Patient and Family Advisory Council. All information contained on this form is confidential and is intended for use only by Hartford Healthcare for the purposes of securing Patient and Family Advisors.*By selecting below I attest that I have read, understand and agree to these conditions.

MEDIA RELEASE I hereby authorize Hartford HealthCare, its employees and agents to make recordings of me, whether audio or images, still or moving, and to alter and composite the same without restriction and without my inspection or approval, for use by Hartford HealthCare for any purpose in any and all media now or hereafter known, and to use my name in connection with said use if it chooses. I understand that this consent cannot be revoked, that it is effective in perpetuity, and that I have no expectation of payment in consideration for my authorization. I hereby release and hold harmless Hartford HealthCare, its employees and agents from all claims and liability relating to said recordings. I agree that a copy of this authorization will be as valid as the original.