TrueHLTH Umbra Participant with Background Check

Have you completed a background check within the past two (2) years that includes the following:

• 7 or more years review for criminal records (state and federal)
• A review of any sex offender registries in your area and a statement from the checker/investigator that no offenses were found
• A review of any healthcare-related licenses you hold or may have held in those 7 or more years and a statement from the checker/investigator that no sanctions were found

If No, please proceed with this application.
If Yes, please email a copy to admin@umbrahealthadvocacy.com and click here to remove the Background Check fee from your order form.

Terms: 1 Year for $158 then $99/year (Auto-renews unless cancelled before the renewal date)

Terms:

1 Year for $158 then $99 / Year

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

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

I have read and agree to the Consumer Health Advocacy, Inc. Advocate Terms and Conditions and Service Level Agreement, including the HIPAA Agreement.*

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