Preceptorship 1 – Independent Practice – Payment Plan After Deposit Terms: First payment is $1,550 then two payments of $874.50 / month Terms: 1 Month for $1,550 then 2 payments of $874.50 / 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 (to match for renewal):* Email (to match for renewal) is Required 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. 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) 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 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 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 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).* 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 No val Please fix the errors above
