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 Premium ADL and Premium
Membership Application

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Not quite ready to fill this out?
Learn more about Premium and Premium ADL memberships.

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Note: This application is long and it cannot be saved if you don't finish it.
Here's a copy of the application for you to review before you begin filling it out.

Remember,
most of the information you supply will show up in your AdvoConnection Directory listing once it goes online. However - don't worry too much about getting it exactly right just yet. Once you have paid your dues, you'll have total access to your Directory listing and will be able to make updates and changes to it at any time.

Fields with * must be included.
 
Application Form  
The following information is administrative and will not be seen by the public.
* Contact Name:
* Contact Email:
(This email address will not be used on the AdvoConnection website.)
* Re-enter Email:
* Contact Phone (with area code):
* Number of advocates and employees:
* Mailing address for corporate office / home location:
address
city
state/province zip/postal code
* Type of membership applying for: Premium ADL       Premium
Compare Premium Memberships
As you know, we review your application to be sure you are ready to be listed in the Advocate Directory. Please supply the following information to help us assess your readiness. If you don't have this information yet, just leave the spaces blank.
How long have you been in business as a private, independent advocate?
What company is your advocacy/navigation business professional liability and/or Errors & Omissions insurance with?
Where can we find online/web information about you and your advocacy/navigation work?
(Websites, LinkedIn, Facebook or others—please give entire links for up to 3 sites)
Choose your login information so you can edit your listing:
* Choose an ID for login
(must be at least 8 characters):

(If you are already a PACE member, you'll need to choose a different ID for this membership. Once you are approved and paid, you can change it to the original PACE ID if you want to.)
* Choose a password:
(must be at least 8 characters)
* Repeat your password choice:
Input information below as you would like it to appear in your listing at the AdvoConnection Directory website. Answer based on what you know today. You will be able to change this information at any time both before and after your listing goes live in the AdvoConnection Directory.
* Name of Advocate or Organization:
* Services provided:
Important! Read about choosing your services here.
Medical / Navigational Assistance (Helping you work with your medical providers.)
Background Research: Diagnosis, Medical Records, Treatment Options and more
Hospital Bedside, or Travel / Accompaniment to Appointments
Shared Decision Making (formal process of benefit to patients - read more in SERVICES)
Medication Reviews: Prescription Drugs, Over-the-Counter, and Supplements
Geriatric / Eldercare or Home Health Services
Integrative, Holistic, Complementary and Alternative Therapies
Mental Health and Substance Abuse Assistance
Pain Management
Pregnancy, Birth and Pediatric Assistance
Health Insurance: Choices and Review
Medical Bills, Claims and Denials: Review, Reduction, Negotiation
Insurance Claim Filing Assistance for Disability or Long Term Care
Guardianship / Conservatorship / Fiduciary Care
Mediation (Helping families manage health-related disagreements)
Legal Assistance including SSDI (Medical / Healthcare Related)
End of Life Decisions, Planning, and Paperwork
Dental Advocacy (from dental decisions to billing problems)
Prevention (Prescription Drug Review, Health/Wellness Coaching, Weight Loss, Immunity, Others)
Other - Please Specify
Medical Tourism - global travel for medical care purposes, to, from or within the US or Canada
Web URL (Address):
* Contact information to be listed publicly:
name
email
phone
   
* Locations:
You MUST fill in *Red Starred questions.
Fill in additional options if they apply to you. Answer based on what you know today. You will be able to change this information at any time both before and after your listing goes live in the AdvoConnection Directory.

Need more help?
Read about designating your location here.
*1. Text description of location:

*2. What is your zip or postal code? (The central code to your office. Any patient who is searching within 200 miles of your zip or postal code will see your listing near the top of their results.)


In addition to the zip or postal code you have supplied, are you able and willing to work with anyone in the same state or province you live and work in? If yes, please select your state or province.


If you are able to travel to other parts of the country (either the US or Canada) to help patients in other locations, and wish to be included in the results for other areas, please choose which country you live and work in:
We serve all of the U.S.    OR:    We serve all of Canada

3. We have a second location, too (optional): What is the zip or postal code?

Are you able and willing to work with anyone in a second state or province? (Leave blank if your second location is in the same state or province specifed above.)


   
Do you belong to any of these organizations?  Check them off if you would like their logo to appear on your listing. You may also be entitled to a discount on your first year dues.  (See Affiliations) CoPatient
CSA (Certified Senior Advisor)
iRNPA
NAHAC
National Institute of Whole Health
NerdWallet
PPAI
University of Toledo (Ohio)
WASHAA
Other:
   
Do you subscribe to the Health Advocate's Code of Conduct and Professional Standards? yes          no
How did you hear about the Alliance of Professional Health Advocates?
   
Logo:
Don't have your logo ready to upload? You will be able to add it later.

It must be a .jpg or .gif or .png, no more than 200px by 200px in size. If you aren't sure about the format, please send your logo in an email to info(at)advoconnection and we will format it for you.
Photo:
Don't have a photo? You will be able to add it later.

It must be a .jpg or .gif or .png, no more than 200px by 200px in size. If you aren't sure about the format, please send your photo in an email to info(at)advoconnection and we will format it for you.
Description of your work:
(Up to 2,000 characters, including spaces and punctuation marks — that's about 250 words)
Please provide a one sentence description of the services you provide and your service area:
For example:
We serve patients in Florida who need help understanding their diagnosis.
Testimonials will be added separately.
Please acknowledge the following:
* I understand that application to be a member of AdvoConnection does not guarantee membership and that no fees will be collected until I have been approved for membership. yes          no
* I understand that once accepted, I will be invoiced. My listing at the patient site and access to my member benefits will be granted upon payment in full. yes          no
* I understand that once accepted, my membership may be revoked at any time by AdvoConnection's site owner. yes          no
* I understand that AdvoConnection takes no responsibility for the quality of my work or outcomes for my patient-customers. yes          no
* I understand that my inclusion on the AdvoConnection website does not guarantee patient-customers will find me, nor that I will acquire any new customers through the site. yes          no
This helps us reduce spam:

NOTE: You will be able to view your online listing and modify it at any time once your membership has been approved.




 

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