Patient and Family Advisory Council

Membership Application

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 a 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 and submit this form.

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 CONTACT INFORMATION

 ABOUT YOU

 YOUR IMPACT AS AN ADVISOR

 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, HIPPA 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.