How to Fill Out the Michigan Patient Advocate Designation Form (DCH-3916)

Michigan’s patient advocate designation form, officially the DCH-3916, lets you name someone to make medical, mental health, and end-of-life decisions for you if two clinicians determine you can no longer make them yourself. Filling it out correctly comes down to a handful of steps: name a primary advocate and at least one successor, mark the specific authority you want to grant, add the required life-sustaining-treatment language if that applies, sign in front of two qualifying witnesses, and have your advocate sign the acceptance page. Miss any of those and the form may not be honored when it matters.

Where to Get the Form

The Michigan Department of Health and Human Services publishes the DCH-3916 as a downloadable document on its website. Printed copies are available through doctor’s offices, hospitals, and community mental health authorities. Michigan health systems sometimes host their own versions with expanded instruction pages, but the legal content is identical.

Naming Your Advocate and a Successor

The first section asks for a patient advocate (the person who will speak for you) and at least one successor who steps in if your first choice declines, becomes incapacitated, resigns, or is removed. Skipping the successor is a common mistake. If you name your spouse as advocate and later file for divorce, separate maintenance, or annulment, the designation is automatically suspended during the proceedings and revoked when the court enters the final judgment.¹ A named successor keeps the form working through that change; without one, you are left with no advocate at all.

For each person, fill in full legal name, street address, city, state, zip, and home, work, and cell phone numbers. Hospital staff use that information to reach your advocate during an emergency. If any of it changes, complete a new form or update and re-sign the existing one with fresh witnesses.

Spelling Out What Your Advocate Can Decide

Michigan law lets you authorize your advocate to make decisions about your care, custody, medical treatment, mental health treatment, and anatomical gifts.² You can grant broad authority across all of these or restrict it to specific categories. The form walks through each area separately so you can decide one at a time.

The mental health section is worth reading slowly. It covers consent to or refusal of outpatient therapy, psychotropic medications, inpatient admission, and electroconvulsive therapy. For mental health decisions, the second clinician who confirms your incapacity can be a licensed psychologist rather than a physician.³

The organ donation section is optional. You can authorize any needed organs or body parts or limit the gift to specific organs, and you can specify whether they may be used for transplantation, therapy, research, or education. This authority continues after your death, unlike the rest of the designation.²

There is also an open “Statement of Wishes” area where you describe the care you want in your own words. You might note that you prefer to stay at home, that a particular doctor or hospital should be involved, or that religious beliefs should guide comfort-care choices. Your advocate leans on this when a situation falls outside the specific powers you granted.³

Life-Sustaining Treatment Language

If you want your advocate to be able to withhold or withdraw treatment that would allow you to die, Michigan requires you to say so in clear and convincing terms within the form itself. A vague reference will not do. The statute specifically requires you to acknowledge that the decision could or would result in your death.² The form provides pre-written language you can adopt covering do-not-resuscitate orders and refusal of tube-fed food and water.³

One hard limit: if you are pregnant, your advocate cannot withhold or withdraw life-sustaining treatment where doing so would result in your death, regardless of what the form says. This overrides your stated wishes for the duration of the pregnancy.

Witness Rules That Invalidate the Form

Michigan does not require notarization. It does require you to sign in the presence of two adult witnesses who also sign the form.⁴ The rules on who can serve are strict, and picking the wrong person voids the designation. The following cannot witness:

Your spouse, parent, child, grandchild, or sibling
Anyone who would inherit from you, through intestacy or as a named beneficiary in your will
The patient advocate you are designating
Your attending physician
Employees of your life or health insurance provider
Employees of the hospital, health facility, home for the aged, or community mental health program where you receive care or reside

Each witness must also believe you appear to be of sound mind and are not signing under duress, fraud, or undue influence.⁴ Neighbors, coworkers, or friends with no connection to your estate or your medical care are usually the safest picks.

The Signature Most People Forget

Your advocate cannot act until they personally sign the “Acceptance of Designation” section on the form. By signing, the advocate confirms they understand the designation only takes effect when you are unable to participate in your own medical or mental health decisions, and that they agree to follow your stated wishes.² Each successor advocate must also receive a copy and sign their own acceptance before stepping in.

This is where forms fail quietly. People complete every other section, line up witnesses, and never get the advocate’s acceptance signature. Without it, a hospital will not honor the document.

When the Form Actually Takes Effect

The designation stays dormant until two things happen. Your attending physician and a second physician must determine, in writing, that you cannot participate in decisions about your medical treatment. For mental health decisions, the second professional can be a licensed psychologist rather than a physician.³ The signed form must also be made part of your medical record.⁴

Once activated, your advocate has only the authority you granted. If you regain the ability to make your own decisions, the advocate’s authority is suspended. It can cycle on and off as your condition changes.

Where to Keep It and Who Should Have a Copy

A completed form only works if the right people can produce it. Keep the original in a secure but accessible place at home, not in a safe deposit box that nobody can open during a weekend emergency. Give copies to your primary advocate, every named successor, and your primary care physician.²

Ask your doctor’s office to upload it into your electronic medical record. Once it is in the system, emergency physicians and hospitalists at connected facilities can see your advocate’s information without anyone having to find a paper copy. If you receive regular care at a specific hospital, give a copy directly to their medical records department as well.

The form includes language granting your advocate access to the medical and mental health records you are entitled to see yourself. That provision generally takes the place of a separate HIPAA authorization once the designation is activated, so the advocate can review your chart and talk with your doctors.

Changing or Revoking the Designation

You can revoke a patient advocate designation at any time, by any method that communicates your intent. That includes telling someone verbally, writing a new document, or destroying the form.¹ No specific revocation form is required.

If you revoke, tell your former advocate directly and retrieve or destroy any copies they hold. Contact every doctor’s office and hospital that has the old form on file so they can replace it in your record. If a divorce ends your spouse’s role, a named successor takes over automatically; if there is no successor, complete a new designation promptly.¹

1
Michigan Legislature. Michigan Compiled Laws 700.5510
2
Michigan Legislature. Michigan Compiled Laws 700.5507
3
Michigan Department of Health and Human Services. Patient Advocate Designation
4
Michigan Legislature. Michigan Compiled Laws 700.5506