New User Details
User ID (verify)
Please create your desired User ID and Password above.
(User ID must be a valid email)
For help contact:
Essentia Health East Volunteer Services 407 East Third Street Duluth, MN 55805 (218)786-4420
Patient Partners/Advisory Council Application
Become a Patient Partner
Is this right for me? Patient Partners are people from all walks of life who have experienced care at Essentia Health.
You can make a difference. Help shape the way healthcare is experienced. Just answer a few questions and submit this form. We'll be in touch soon.
YES! I'm interested and would like to be considered for:
Duluth- Chronic Pain Rehabilitation
Duluth- Heart & Vascular
Duluth- Miller-Dwan Rehab
Duluth- Polinsky Outpatient Rehab
Duluth- Primary Care
Duluth- Women and Children
Gender and Sexual Diversity
If Other, please list:
No, I'm not ready at this time, but please keep in touch by sending me updates.
How do you prefer to be contacted?
Do you or your spouse/partner or family members work for Essentia Health?
Yes, I or my children/dependents/spouse receive or have received care at Essentia Health.
Please briefly describe the kinds of care you or the person(s) you care for receive at Essentia Health:
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.
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.
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.
Patient Partners/Advisory Council Form 2017