Join AdvoConnection :: Application form for Patient Advocates and Navigators



AdvoConnection: Helping Patients' Advocates Find Their Target Audiences
ADVOCONNECTION Membership Application

Membership Application for AdvoConnection
This application is for members who will be listed in the patient advocate directory.

Please do not use this application if you represent a non-profit organization or if you are not yet working as a private patient advocate. Learn more here.

Basic
Membership

Premium
Membership

Business
Membership

If you are an individual
advocate joining for yourself
(even if you work for a larger
organization) you may
apply to be a
Basic Member of
AdvoConnection.

If you are an individual advocate joining for yourself (even if you work for a larger organization) you may apply to be a
Premium Member of AdvoConnection.

If you represent a for-profit advocacy business and wish to join on behalf of your employees or contractors, you may apply for a
Business Membership in AdvoConnection.

Learn more about the
Basic Membership Plan

Learn more about the
Premium Membership Plan

Learn more about the
Business Membership Plan

Basic Membership
dues are $99/year

Members of
NAHAC:
$79/year

Premium Membership
dues are $249 / year

Members of
NAHAC:
$209/year

Business Membership
dues are $799 / year
for 5 advocates (premium level) plus a business listing
(6 listings total).
Additional advocates may be included for $150 each

Note: Memberships are not automatic. Your application must be approved before your listing is viewable on the AdvoConnection patient directory website. Site owner claims a right of refusal for any listings.
No fees will be invoiced or collected until membership has been accepted.

Questions about membership benefits, the plans, or your listing?
Contact us at: info (at) AdvoConnection.com

Application Form

Fields with * must be included.

The following information is administrative and will not be seen by the public.

* Contact Name:

* Contact Email:
(This email address will be used in conjunction with membership, but not 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:
Not sure which membership to choose?

Basic
Premium
Business

Choose your login information so you can edit your listing:

* Choose an ID for login
(must be at least 8 characters):

* 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 patient website:

* 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, Treatment Options and more
Hospital Bedside, or Travel / Accompaniment to Appointments
Geriatric / Eldercare or Home Health Services
Medical Billing / Health Insurance / Payer Assistance
Pregnancy, Birth and Pediatric Assistance
Integrative, Holistic, Complementary and Alternative Therapies
Prevention (Prescription Drug Review, Health/Wellness Coaching, Weight Loss, Immunity, Others)
Legal Assistance including SSI (Medical / Healthcare Related)
Other - Please Specify

Web URL (Address):

* Contact information to be listed publicly:

name
email
phone

* Locations:
Important! Read about designating your location here.

1. Text description of location:

2. Choose one:
We serve all of the U.S. OR: We serve all of Canada

OR:

We provide services anywhere within this state or province:

OR:

We will provide services within a 200-mile radius of this location: ZIP/Postal Code:
We have a second location, too: ZIP/Postal Code:

Please contact me. We have additional, specific locations.

Do you belong to any advocacy organizations?

NAHAC
Other:

Premium and Business Membership Applications should also fill out the following:

Logo or photo:
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 or 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

When you hit the SUBMIT button, you will be taken to a review page where you will approve the contents of this form before your membership is submitted for acceptance.

AdvoConnection.com is one of the DiagKNOWsis family of websites.