Bristol Regional - Patient & Family Advisory Counsel

Ballad Health Patient & Family Advisory Counsel Application

Bristol Regional Medical Center
Confidentiality notice: The information you share in this form is private. It will be used to help the Ballad Health Patient & Family Advisory Council Committee review your application. We will keep your personal details safe and follow HIPAA privacy rules. To learn more, you can read Ballad Health’s full Privacy Policy at: https://www.balladhealth.org/privacy-policy.
Was your care experience in the past year? This could be at a hospital or clinic. It’s okay if you were there as a support person rather than a patient.

YesNoI was not a patient or support person, but I am an interested community member.
What was your care experience at Bristol Regional Medical Center? Select all that apply.

I was a patient.My family member was a patient and I went with them to the hospital.I was a support person or caregiver to a patient in the hospital.I was not a patient or support person, but I am an interested community member.

Ballad Health Patient & Family Advisory Counsel Application

Bristol Regional Medical Center
Confidentiality notice: The information you provide on this form will be kept confidential and used only for the Ballad Health Patient & Family Advisory Council Committee. It will not be shared with third parties without your consent. To learn more, you can read Ballad Health’s full Privacy Policy at: https://www.balladhealth.org/privacy-policy.
Do you give your consent for Ballad Health to review your application and contact you about the Patient & Family Advisory Council?

Yes, I consent.
By typing your name below, you confirm that the information you’ve shared is true to the best of your knowledge. Your name will serve as your digital signature.
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Ballad Health Patient & Family Advisory Counsel Application