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UCS Healthcare Patient Advisory Group (UPAG) Membership Application

What are your commitments as a UPAG member?

Choosing to serve on the UPAG means you agree to:

Talk openly with other patients and UCS Healthcare team about how to make the experience better for all patients and families.
Actively take part in UPAG meetings in a meaningful and respectful way.
Show compassionate interpersonal skills, such as: actively listening to others; sharing your ideas in a positive way; working with other UPAG whose own perspective, background experiences, and styles that are likely very different from your own.
Attend at least 75% of the scheduled meetings each year.

Full Name

Street Address

City, State and Zip Code

Phone Number

Main UCS Healthcare Provider/Service

Number of Years as a UCS Healthcare Patient

Please Answer the Following Questions:

1) Why would you like to serve on the UCS Healthcare Patient Advisory Group (UPAG)?

3) Please write about the medical condition(s) you have faced that we have helped you with at UCS Healthcare.

4) What are some of the things our team at UCS Healthcare has done to help you and your family?

5) What are some of the things our team could do differently to improve the care of you or your family member?

By checking the box and entering my name below, I verify all information on this application is true & I agree to the UPAG commitments.

Full Name

Date of Submission