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Since 1978, the Global Leader in Advancing Patient-Centered Care

Planetree Patient Preference Passport

Planetree Patient Preferences Passport National Demonstration Project

The following application has been developed for selecting organizations to participate in Planetree’s National Demonstration Project for the Patient Preferences Passport.  Completion of this application is the first step in the selection process. Upon receipt of your application, a member of the Planetree team will contact you to review the organizational requirements as well as the costs associated with participating in this project.

Please review the following expectations of all participants of this demonstration project, and indicate your understanding and ability to participate as described.  All organizations selected to take part in the demonstration project agree to the following:

  • A three year comprehensive roll-out of the Patient Preference Passport.
  • Use of members of your Patient and Family Advisory Council as passport facilitators.
  • Identification of an internal coordinator as a partner for Planetree.
  •  Use of an identified patient activation measure pre and post implementation.
  • Education of ALL staff, physicians and advanced practitioners.
  • Recruitment and training of volunteer Passport Facilitators from internal stakeholder groups: staff, volunteers and providers.
  • Development and deployment of an internal and external communications plan.
  • Making volunteer Passport Facilitators available for community events and education.
  • Attendance at quarterly virtual learning and networking sessions with other demonstration project sites.
  • Sharing of the pre-post data for a joint publication at the end of the demonstration project.

Deadline to Submit: March 9th


I have read and understand the terms for participating in the demonstration project
My application has been reviewed with my CEO/COO
Phone Number
Email Address:
Type of Organization
If you checked "other" please describe your organization
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