Patient Partners

For help contact:

Essentia Health East Volunteer Services

VolunteerServices@essentiahealth.org

(218)786-4420

Patient and Family Advisory Council Application

Patient and Family Advisors are people from all walks of life who have experienced care at Essentia Health. Essentia Health employees and their spouses/partners or immediate relatives are not eligible for membership as Patient or Family Advisors on the Council.

Submit this application and a staff member will be in touch shortly to talk more about volunteering on a Patient and Family Advisory Council.

**Please advise us if any accommodation is needed to participate in the application process.**

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Advisory Council:

Council Member Type

Council Member Type: Other

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Personal Information

* Family/last name

* First name

Middle name

* Address

* City

* State

* Zip/postal

* E-mail

* Phone

Preferred Contact Method

Emergency Contact

* Name

Relationship

* Phone

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Type of facility providing care

* Please briefly describe why you would like to be a Patient/Family Advisor:

Essentia Health Confidentiality Agreement

* I understand that I have the responsibility to ask questions and obtain additional information as needed.

* I agree to keep confidential all information that I may hear directly or indirectly concerning Essentia Health, patients, physicians, other professional staff, employees, or any other volunteers and will not seek confidential information in regard to the same.

* I agree to adhere to the HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations as viewed in the Essentia Health HIPAA Penalities Policy.

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I hereby authorize investigation of all statements contained in this application. I further authorize my reference permission to furnish Essentia Health East with facts and opinions as to my job performance, capabilities and desirability as a volunteer. I further release all persons whomsoever from any damage because of furnishing said information.

* The information in this application is accurate and correct to the best of my knowledge.

I agree as a volunteer my time and talents will be given freely without any expectation of monetary reimbursement.

* My typed name shall have the same force and effect as my written signature.

* Your Signature

* Date

Volunteer opportunities are provided without regard to religion, creed, race, national origin, sexual orientation, age, gender, disability, marital status or status with regard to public assistance. Essentia Health East does not imply that you will be assigned a volunteer position and this application should not be construed as a contract or promise of a volunteer position.