Patient Family Advisory Council Application

Thank you for your interest in the Patient Family Advisory Council! Membership on any of our councils requires your successful completion and submission of the below application and our registration process, including but not limited to: a health screening which includes TB testing, a criminal background check, a formal interview process, as well as a mandatory advisor orientation. All of your information will be treated as confidential. Membership on any of our councils requires attendance at monthly council meetings. Applicants must be 18 years of age or older. Council members will demonstrate a readiness to help others, maintain respect for collaboration and assist SBM in delivering quality patient-centered care.

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Acknowledgement & Authorization
I hereby affirm that this application and all document submitted to me in connection with my application for an advisor contain no willful misrepresentations and that the information given by me is true and complete. I understand that any false statements of misleading omissions made by me in connection with my application, or in responding to any requests for information can be sufficient grounds for my rejection as a candidate for an advisor or my immediate termination and/or referral for criminal prosecution.

I agree if accepted as an advisor to abide by all rules, policies and regulations of Stony Brook Medicine. I certify that the information that I have provided is complete and accurate. I agree to abide by the guidelines of the Advisory Board, to respect patient confidentiality, and to uphold the traditions of SBM.