Payment Plan Test 5000.00500 Terms: 1 Day for $500 then 2 payments of $499 / Month First Name:* First Name Required Last Name:* Last Name Required Address:* Address is Required City:* City is Required State or Province:* State or Province is Required Zip or Postal Code:* Zip or Postal Code is Required Country: Country is not valid USA Canada Other Country (Outside US and Canada): Country (Outside US and Canada) is not valid Phone number:* Phone number is Required Email:* Email is Required Education: Education is not valid Briefly describe your relevant educational background. Experience: Experience is not valid Briefly describe your advocacy experience, paid or volunteer. Current APHA Membership:* Current APHA Membership is Required I am currently a PACE or PACE International Member I am currently a Premium member I am currently an Umbra Associate Member I am not an APHA Member This program is designed to help clinicians transition into patient advocacy. Do you have clinical training and/or experience? : This program is designed to help clinicians transition into patient advocacy. Do you have clinical training and/or experience? is not valid Yes No What kind of patient advocacy career do you envision for yourself?: What kind of patient advocacy career do you envision for yourself? is not valid I want to open my own independent practice as soon as I can. I want to provide advocacy services but I don’t want to start or run my own business. I want to get started serving clients as soon as possible without having to do all the set up, but later I may want to launch my own practice. Which of the following organizations are you a member of, or participant in?: Which of the following organizations are you a member of, or participant in? is not valid CSA (Certified Senior Advisor) iRNPA National Institute of Whole Health WASHAA Assumption College Cleveland State None of the Above Why are you interested in advocacy as a career?: Why are you interested in advocacy as a career? is not valid Web Presence: Web Presence is not valid Liability Insurance:* Liability Insurance is Required Are you currently an APHA Member?: Are you currently an APHA Member? is not valid Do you hold any of these certifications?:* Do you hold any of these certifications? is Required Board-Certified Patient Advocate (BCPA) Certified Senior Advisor (CSA) Certified Life Care Planner (CLCP) Certified Geriatric Care Manager (CGCM) Certified Medical Coder (CMC) Certified Case Manager (CCM) Social Worker (LCSW, MSW) Registered Nurse (RN) Certified Nurse Practitioner (CNP) Physicians Assistant (PA) Medical Doctor (MD) Pharmacist (PharmD) Occupational Therapist (OT) Physical Therapist (PT) Chiropractor (DC) Medical Assistant (CMA) Certified Nurse Assistant (CNA) Other None of the Above Where did you hear about the Alliance of Professional Health Advocates?: Where did you hear about the Alliance of Professional Health Advocates? is not valid Your experience (Please check all that apply):* Your experience (Please check all that apply) is Required I have worked in a healthcare administrative role I have worked in a healthcare clinical role I have been an unpaid caregiver I have been a non-clinical paid caregiver I have had training in patient advocacy/care management/care coordination None of the above Which of the following do you have experience doing? (Please check all that apply):* Which of the following do you have experience doing? (Please check all that apply) is Required Managing health insurance and/or pharmacy benefit issues such as prior/pre authorization, step therapy, denials/appeals, and/or filing medical claims Scheduling appointments, arranging transportation, care coordination, tracking paperwork/records Communicating with medical/service providers, patient education Navigating for additional financial or other assistance (e.g. Disability) for those in need Managing/reducing hospital bills Other If other, please specify:: If other, please specify: is not valid Do you have experience advocating for patients with inflammatory bowel disease (IBD), including Crohn’s and/or ulcerative colitis?:* Do you have experience advocating for patients with inflammatory bowel disease (IBD), including Crohn’s and/or ulcerative colitis? is Required Yes No If yes, please describe your experience with IBD navigation/advocacy: If yes, please describe your experience with IBD navigation/advocacy is not valid If no, are you willing to complete APHA/Umbra training module/s on IBD specifically?:* If no, are you willing to complete APHA/Umbra training module/s on IBD specifically? is Required Yes No Please include your bio or a link to an online bio for you. Either keep it brief (up to 150 words) or include your full bio and we will trim it for you.: Please include your bio or a link to an online bio for you. Either keep it brief (up to 150 words) or include your full bio and we will trim it for you. is not valid Do you have Professional Liability / Errors and Omissions insurance?:* Do you have Professional Liability / Errors and Omissions insurance? is Required Yes No Has there been a claim against you in the past seven years?:* Has there been a claim against you in the past seven years? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Do you have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim against you?:* Do you have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim against you? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Have you ever been turned down (declined) for Errors & Omissions or Professional Liability insurance?:* Have you ever been turned down (declined) for Errors & Omissions or Professional Liability insurance? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Have you ever had Errors & Omissions or Professional Liability insurance that was canceled?:* Have you ever had Errors & Omissions or Professional Liability insurance that was canceled? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Have you ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association?:* Have you ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?:* Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? is Required Yes No If Yes, please explain: If Yes, please explain is not valid Have you ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered the same?:* Have you ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered the same? is Required Yes No If Yes, please explain: If Yes, please explain is not valid What is your hourly rate?:* What is your hourly rate? is Required What will you charge for 5 hours of time? (We’d like to offer discounts for clients who sign up for larger blocks of time.):* What will you charge for 5 hours of time? (We’d like to offer discounts for clients who sign up for larger blocks of time.) is Required What will you charge for 10 hours of time? (We’d like to offer discounts for clients who sign up for larger blocks of time.):* What will you charge for 10 hours of time? (We’d like to offer discounts for clients who sign up for larger blocks of time.) is Required Are you a current ALCA member?:* Are you a current ALCA member? is Required Yes No Please share the link to your GNA profile page: Please share the link to your GNA profile page is not valid Click here if you’d like to be listed in the Umbra Health Advocacy Directory. (You’ll get a notification when your listing is live and instructions for how to manage or update it.) By registering for this program, you agree to the following confidentiality terms::* By registering for this program, you agree to the following confidentiality terms: is Required I acknowledge that during the course of this program, I may be exposed to proprietary or confidential information, including, but not limited to trade secrets, programs, technical data, financial information, identities or lists of clients, prospects, patient information, pricing, suppliers or vendors, key employees, and personnel data in oral and/or written form (“Confidential Information”). I agree to treat Confidential Information in strictest confidence and will not disclose it to third parties unless the information (1) was part of the public domain when received or becomes a part of the public domain through no action or lack of action on my part; (2) prior to disclosure, was already in my possession and not subject to an obligation of confidence imposed in another relationship; or (3) subsequent to disclosure, is obtained from a third party who is lawfully in possession of the information. In the event that I am requested under the terms of a subpoena or order or other compulsory instrument issued by or under the authority of a court of competent jurisdiction or by a governmental agency, or am advised by my counsel that there is otherwise a legal obligation to disclose (i) all or any part of Confidential Information; or (ii) the fact that Confidential Information has been made available to me, then I shall (a) promptly notify the Alliance of Professional Health Advocates of such request so that it may seek an appropriate protective order or waive compliance with this agreement; and (b) if disclosure of Confidential Information is required, shall furnish only such portion of Confidential Information as Advocate is advised in writing by my counsel is legally required to be disclosed. In connection with such compelled disclosure, I shall use reasonable efforts to obtain from the third party to whom disclosure is made written assurance that confidential treatment will be accorded to such portion of Confidential Information as is disclosed. I have read and agree to the APHA Membership Terms Of Service* I have read and agree to the APHA Membership Terms Of Service and the Consumer Health Advocacy, Inc. Advocate Terms and Conditions and Service Level Agreement if you are signing up for Path 2 (including Umbra Associate Membership).* I have read and agree to the APHA Membership Terms Of Service and the Consumer Health Advocacy, Inc. Advocate Terms and Conditions and Service Level Agreement.* I have read and agree to the Consumer Health Advocacy, Inc. Advocate Terms and Conditions and Service Level Agreement, including the HIPAA Agreement.* Please list any certifications or other training/credentials you have (For example; BCPA, RN, PA, PA-C, OTR, DO, etc): Please list any certifications or other training/credentials you have (For example; BCPA, RN, PA, PA-C, OTR, DO, etc) is not valid What, if any, area of advocacy or patient group or population do you plan to focus on? (It’s ok if you don’t know yet.): What, if any, area of advocacy or patient group or population do you plan to focus on? (It’s ok if you don’t know yet.) is not valid What do you hope to get out of Patient Advocacy Boot Camp?: What do you hope to get out of Patient Advocacy Boot Camp? is not valid How did you hear about Patient Advocacy Boot Camp?: How did you hear about Patient Advocacy Boot Camp? is not valid Taste of Patient Advocacy session Pre-registration updates APHA website Social Media Friend or colleague Other If Other, please specify:: If Other, please specify: is not valid Comments or Questions: Comments or Questions is not valid Did an APHA member refer you? Please give us their name so we can thank them!: Did an APHA member refer you? Please give us their name so we can thank them! is not valid Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Password Strength Password must be "Medium" or stronger Have a coupon? Coupon Code: Invalid Coupon Coupon applied successfully Check, Bank, or Money Order (Delayed Access) To pay by check, bank or money order, check this box. The next page will bring up an invoice. Hit the SUBMIT button on the invoice to access mailing instructions. Credit Card by Phone We can take your credit card by phone for an extra $5 charge. The next page will bring up an invoice. Hit the SUBMIT button on the invoice to make arrangements to pay by phone. Upgrade Pricing You will see the full Premium price on the next page. Ignore it! We'll be doing discount math for you. Just click on the SUBMIT button on that invoice page for your Next Steps. Existing Member Existing Members will be manually approved for our new site. You'll receive a notice as quickly as possible that you have been approved, along with log-in information. Credit Card (Immediate Access) Pay with your credit card via Stripe No val Please fix the errors above
