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Umbra Associate Membership Application

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

Please complete the application below.
Once you submit the application, follow the prompts to complete payment.
You must complete a background check. Once you submit the application and complete payment, you will receive a link to complete the background check.
Umbra Associate membership renews automatically each year. You can cancel at any time for the following year if you do not want your membership to renew.

*Required Fields

Terms:

1 Year for $958 then $899 / 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:* Email 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

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

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.*

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An activity of Consumer Health Advocacy, Inc.
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