Patient and Family Advisor

Thank you for your interest in being a patient/family advisor. Please fill out the below form with as much detail as possible so that we can understand your experiences as a patient or family member. This information helps us match your interests with available opportunities.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information

* First or Preferred Name

* Last Name

* Mailing Address

* City

* State

* Zip Code

* Cell Phone

Home Phone (if different)

* E-mail Address

* Date of Birth (mo/day/year)

Social Security Number (if international please add nine 0)

* Name of Emergency Contact

* Relationship

* Phone

Patient/Family Experience:

Please check if you are or have been:

When was your and/or your family member's most recent appointment at BIDMC?

What care services have you and/or your family member received at BIDMC? Please check all that apply.

If other, please specify:

* Please provide an example of a positive experience you have had at BIDMC:

* Please provide an example of an experience that could have gone better:

* Please tell us why you are interested in being an advisor:

We strive to have a team of advisors who reflect the diversity of the patients and families we serve. Please share anything about yourself that you think could add to the diversity of our team of advisors. Examples: race, ethnicity, religion, gender identity, sexual orientation, education level, health condition, family structure, age, language, life experiences.

Optional - What is the highest level of education you have completed?

To the best of your knowledge, are you eligible to work within all federal health care programs, state health care programs, and federal procurement or non-procurement programs?

Have you been excluded, suspended, debarred, or otherwise ineligible from working within any federal health care programs, state health care programs, or within federal procurement or non-procurement programs?

Optional - Upload a photo of yourself

PLEASE READ CAREFULLY AND CHECK "I AGREE" BELOW

I certify that the information given above is true and complete and I understand that misrepresentation and/or withholding of information will result in the rejection of this application or my discharge if discovered after volunteer service begins. I authorize the Medical Center to make inquiries regarding my history and character of prior employers, schools, etc. and hereby release employers, schools or individuals from all liability in responding to inquiries in connection with my application and release the Medical Center from all liability with respect to such inquiries.

I understand that if I am a volunteer, I will be a volunteer "at will" and may terminate my volunteer assignment at any time with or without cause or notice and that the Medical Center also has that right. I also understand no representative of the Medical Center, other than the President, has any authority to enter into any agreement for volunteer service for any specified period of time or to make any agreement contrary to the foregoing and that such agreement must be in writing. As a volunteer, I agree to abide by the Medical Center's policies, rules and procedures and any changes thereto.

I understand that I must provide the Medical Center with updated immunization records that include verification of a Tuberculosis test within the past year. If under 18 years of age, please use the enclosed parental consent form.

* I Agree