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Patient-Family Advisory Council PFAC Application Name Address City State Zip Code Telephone Cell Phone Fax Number Email Address Will you allow your contact information to be shared with other council members I am Yes No A patient A family member of a patient Program/Department and Services involved in your care Your care was primarily Inpatient Outpatient Both inpatient and outpatient Clinics Other Programs departments or services explain Why would you like to serve as an advisor New...
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To fill out a yes-no Samaritan form, follow these steps:
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Begin filling out the form by providing your personal information such as your name, address, and contact details.
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