Patient and Family Advisor Application Form

Thank you for your interest in joining Cascade Medicals’ Patient & Family Advisory Council (PFAC). The council will have an active role improving patient and family care experiences within Cascade Medical by gathering and providing feedback and perspectives on medical group plans, activities, and programs related to patient and family centered health care.

Eligibility

Membership requires a minimum of 2year to maximum 3year commitment, with an opportunity to serve for 2 terms.
Members must be able to commit to attending bi-monthly council meetings and possibly participate on committees and/or projects (some of which require daytime hours). Meetings are approximately once every other month, 5-6 total meetings/year.

If you are interested in this program, please complete the following application, and submit it to the Patient & Family Advisory Council for review. Selected applications will be contacted by the PFAC Staff Liaison to set up an interview and 2-3 weeks after the application deadline.

Application Deadline: April 30th, 2023

If you have any questions, please feel free to call or email: Jade Wolfe PFAC Staff Liaison, 509.699.3066 | Jade.wolfe@cascademedical.org

First Name *

Last Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Phone *

Email *

Preferred contact (check one) *

Phone

The following questions will help us get to know you better.

Please select all that apply below: *

Are you a… *

Patient at Cascade Medical

Family member of a patient at Cascade Medical

A patient with a chronic health condition (e.g., diabetes, heart failure, COPD, depression, arthritis)

I am involved in the care of a Cascade Medical patient who has a chronic condition

I am a patient/family member receiving preventative and/or occasional illness care

When was your or your family member’s last care experience at Cascade Medical? *

Which unit(s) provided care for you or your family member: (check all that apply) *

Emergency Department

Family Practice Clinic

Acute Care (Inpatient hospital level of care for short-term treatment for injury/condition/illness)

Behavioral Health

Sub-Acute Rehab (also referred to as a “Swing Bed”, provides skilled nursing facility “SNF”care, helps patients get stronger after acute hospital stay before going home)

Rehabilitation Services (Physical Therapy, Occupational Therapy, Speech-Language Therapy)

Lab/Diagnostic Imaging

Endoscopy

We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one) *

Less than 1 hour per month

1 to 2 hours per month

3 to 4 hours per month

More than 4 hours per month

Mark all days and times you are available for Monthly PFAC meetings.

Why do you want to become a patient and family advisor? *

Briefly describe any experience you may have as an advisor, as an active volunteer, or as a public speaker. *

Describe any specific things that doctors, or facility staff did or said while you or your family member were in the hospital that were helpful to you or your family. *

Describe any specific things that doctors, and facility staff could have done differently to be more helpful while you or your family member were in the hospital. *

Our patient and family advisors reflect the full range of experiences of the patients and families we serve. Please share anything about yourself that you think would add to our team of advisors. *

(Optional) Is there anything else you would like us to know about you?

Please tell us how you heard about Cascade Medical’s PFAC: *

Approached by Cascade Medical Staff

Website

Brochure and/or Flyer

Other…

Please select one of the following age groups you are in: *

18-25

26-40

41-60

60+

I certify that the statements made in this application are true and correct and have been given voluntarily. If selected, I understand that I will not be paid for my services as a volunteer member of the Patient and Family Advisory Council. I agree to abide by the guidelines of Volunteer Services, to respect patient confidentiality, and to uphold the traditions, values, and standards of Cascade Medical. I understand that completion of this application does not bind me, the applicant, in any way. Cascade Medical reserves the right to choose participants that best meet the needs of the Patient and Family Advisory Council. Before participating in the Council, I understand that I will be asked to sign a confidentiality agreement.

Signature *

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Date *

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Patient and Family Advisor Application Form

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