PracticePartner Membership Application

PracticePartner members get the benefits of Premium membership plus an onramp into a patient advocacy practice. Take these steps to become a PracticePartner member:

1. Please complete the application below. The annual membership fee includes a $59 non-refundable application fee.
2. Once you submit the application, follow the prompts to complete payment.
3. You must complete a background check. Once you submit the application and complete payment, you will receive a link to complete the background check.

Please note:

1. PracticePartner Monthly membership is $149 for the first month, then $129 per month, with a 12-month financial commitment
2. If canceled before the end of the term, the remaining balance is still due
3. Memberships auto-renew month-to-month after the initial 12 months, unless canceled
4. No refunds will be issued for monthly payments under any circumstances
5. Submission can take up to a full minute. You do not need to click on SUBMIT more than once.

*Required Fields

Terms:

1 Month for $149 then $129 / 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: 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

Current APHA Membership

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 a PracticePartner Member I am not an APHA Member

Do you hold any of these certifications?

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

Your experience (Please check all that apply)

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 I have provided informal advocacy services for family and/or friends None of the above

Do you have Professional Liability / Errors and Omissions insurance?

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?:* 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?:* 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?:* 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?:* 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?:* 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?:* 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?:* 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

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.*

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

I understand this is a 12-month commitment with automatic monthly charges, that early cancellation does not waive the remaining balance, that my membership will auto-renew after the initial term, and that payments are non-refundable.*

Username:* Invalid Username

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

Credit Card (Immediate Access)

Pay with your credit card via Stripe

PayPal

Pay via your PayPal account

 

No val Please fix the errors above