Choosing My Patient Advocate - Saint Joseph Mercy Health System

h. The patient may waive the right to revoke adesignation as to the power to exercise mentalhealth treatment decisions, and if such waiver ismade, the patient’s ability to revoke as to certaintreatment will be delayed for 30 days afterthe patient communicates his or her intent torevoke.i. I may revoke my acceptance of my role asPatient Advocate any time and in any mannersufficient to communicate an intent to revoke.j. A patient admitted to a health facility or agencyhas the rights enumerated in Section 20201 ofthe Michigan Public Health Code, 1978 PA 368,MCL 333.20201.If I am unavailable to act after reasonable effort to contact me, I delegate my authority to the persons thepatient has designed as alternate Patient Advocate. The alternate Patient Advocate is authorized to act until Ibecome available to act.PATIENT ADVOCATESignature: ______________________________________________________ Date: _________________Name (please print):_____________________________________________________________________Address:_______________________________________________________________________________Home Phone:__________________________________ Work Phone: _____________________________Cell Phone:__________________________________ALTERNATE PATIENT ADVOCATESignature: ______________________________________________________ Date: _________________Name (please print):_____________________________________________________________________Address:_______________________________________________________________________________Home Phone:__________________________________ Work Phone: _____________________________Cell Phone:__________________________________Advance Care Planning Programc/o Medical RecordsSaint Joseph Mercy Health System5301 East Huron River DriveP.O. Box 995Ann Arbor, Michigan 48106-0995Medical Records Fax 734-712-7387www.sjmercyhealth.org292355 N 6/08 (M) (09450)