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- Part 3 of 4 -

Patient Advocate Agreement

A patient advocate agreement can help you and your advocate decide how your advocate can best provide you with the support you need. Please read through this information and fill out the form at the bottom of this page.

  • What is a patient advocate?
    A patient advocate is a person you choose to support you and act on your behalf. He or she will talk with your healthcare providers. Their actions on your behalf are based on your wishes. A patient advocate cannot make their own decisions about your healthcare.
  • Why do people need advocates?
    Some people may have trouble stating their feelings and concerns. They may be afraid to speak out. They may not understand what is said or what is happening to them. They may be too ill to speak up.
  • What are some tips on selecting an advocate?
    • Decide on an advocate before you are ill. • Choose someone you can talk with and trust. • Choose someone who can keep your information completely confidential. • Decide what qualities you think you need in an advocate e.g. good listener, clearly explains things, courteous, respectful and assertive. • Discuss your expectations with a possible advocate. Ask if he or she is willing and able to do these tasks. • Once the advocate agrees, complete the patient advocate agreement.
  • What is the difference between a patient advocate and a healthcare proxy?
    A patient advocate talks with you, supports you, and acts on your behalf according to your instructions. A healthcare proxy acts for you if you are not able to make judgments and express your wishes. You choose and name that person in your healthcare directive (living will).
  • Where can I get more information on provincial healthcare programs and services?
    You can go to the Manitoba Health website or phone 1-866-626-4862.
  • How does this agreement relate to privacy legislation?
    This agreement meets the requirements in sections 60 (1) Personal Health Information Act and 79 (a) Freedom of Information and Protection of Privacy Act allowing the advocate to have access to personal health information and personal information.

For tips on advocating for yourself and others go to: and

Endorsed by:
CancerCare Manitoba - Interlake-Eastern Regional Health Authority - Northern Health Region - Prairie Mountain Health - Southern Health-Santé Sud - Winnipeg Regional Health Authority

Instructions to Patient:
1. Discuss the information with your advocate(s) before you complete this agreement.
2. Complete and sign the agreement.
3. Have your patient advocate sign this agreement. 
4. This form will be submitted to Daughter On Call and we will add it to your file.
5. Review this agreement from time to time as your wishes may change.

Patient Advocate Agreement

Please fill this out with your Advocate.

I give permission to my patient advocate to do the following (Check as many as you wish):

The information in this agreement is given to help you. It is not professional legal or medical advice. The Manitoba Institute for Patient Safety is not responsible for any loss, damage, or injury arising from a person acting as a patient advocate, or a person using the information on this document or the website (

Signing this agreement means that we have read the entire agreement, including the frequently asked questions and answers, and we accept this disclaimer.

Thank you for filling out this form.

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