Patient & Family Advisor Application Beatrice Community Hospital & Health Center

First Name: *

Middle Initial:

Last Name: *

Address: *

City: *

State: *

ZIP: *

Phone: *

Email:

What is the best way to contact you?

Please check all that apply below:

I am or have been a patient at Beatrice Community Hospital

I am the family member of someone who is or has been a patient at Beatrice Community Hospital

HISTORY OF SERVICE UTILIZED BY BEATRICE COMMUNITY HOSPITAL

Please check all that apply below:

Primary Care Clinic

Specialty Care Clinic

OB/GYN Clinic

Children's Clinic

Radiology, Lab, Respiratory Therapy, Physical Speech Or Occupational Therapy

Emergency Services

Surgical Services

Inpatient Hospital Stays

Skills & Interest

If you wish to provide more information, please use the space below to describe any special training, interests, hobbies, or experiences you feel could be valuable to your work as a Patient/Family Advisor with us.

Please indicate your motivation for wanting to serve as a patient/family advisor for Beatrice Community Hospital:

Please check the Day and Time(s) you are available to meet for an interview and/or informational session:

Monday

Tuesday

Wednesday

Thursday

Friday

Demographic Information

This information is optional for you to provide. We utilize the demographic information for the sole purpose of trying to build a patient and family advisory group that reflects the diverse backgrounds and healthcare experiences of our patient population:

Gender:

Race:

Primary Language:

Age:

Primary Insurance

Your responses are important in planning your involvement with us. If you have any questions concerning the program or this application, please contact:

Jesse Young | Senior Executive Ancillary Services
Beatrice Community Hospital & Health Center
4800 Hospital Parkway | Beatrice, NE 68310
Office: 402-223-7307 | Fax: 402-223-6530
Email: jkyoung@bchhc.org

BCHHC

Participant Information

First Name: *

Middle Initial:

Last Name: *

Address: *

City: *

State: *

ZIP: *

Phone: *

Email:

What is the best way to contact you?

Please check all that apply below:

HISTORY OF SERVICE UTILIZED BY BEATRICE COMMUNITY HOSPITAL

Please check all that apply below:

Skills & Interest

Please check the Day and Time(s) you are available to meet for an interview and/or informational session:

Demographic Information

Gender:

Race:

Primary Language:

Age:

Primary Insurance