BeHealthy Partnership Patient and Family
Advisory Council Member Application
Time to complete this application: 10 min
Name
Address (Street, City, State & Zip Code)
Date of Birth
/
Month
/
Day
Year
Date
Email Address
BeHealthy Member ID Number
What language are you most comfortable speaking?
English
Spanish
Other
If you are a family member what is your relationship to the member?
Parent/Guardian
Child
Spouse
Sibling
Aunt/Uncle
Grandparent
Grandchild
Other
Are you, or a family member, a patient at any of the below health centers or primary care offices?
Baystate Primary Care – Feeding Hills
Baystate Primary Care – Longmeadow
Baystate Primary Care – Palmer
Brightwood Health Center
Baystate General Pediatrics
High Street Health Center
Mason Square Neighborhood Health Center
Northern Edge Adult and Pediatric Medicine
Baystate Primary Care – Westfield
West Side Adult Medicine
Baystate Medical Practices Adult Medicine – Wilbraham
Quabbin Adult Medicine – Belchertown
Baystate Family Medicine – Greenfield
Baystate Family Medicine
Baystate Medical Practices Adult Medicine – South Hadley
Quabbin Pediatrics Medicine
Have you been a volunteer in the past? (Select all that apply)
Another Patient Family Advisory Council
Another advisory board, committee, or council
Volunteer for your church/faith organization
A school-based committee (Parent Teacher Organization, booster club, etc.)
Board of Directors or Trustees
Other
How did you hear about the BeHealthy Partnership(BHP) Patient and Family Advisory Council?
BHP website or social media
Internet
Social Media
Your health center/staff
BHP directly
Other
Why do you want to serve on the PFAC?
Thank You!
We thank you for your interest and look forward to your continued involvement.
Submit
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