Join AdvoConnection :: Application form for Patient Advocates and Navigators



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

Membership Application for AdvoConnection

All three of these memberships are "listed" memberships.
They result in a listing at www.AdvoConnection.com for patients or caregivers to find.
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.

Directory Only
Membership

Premium
Membership

Business
Membership

If you have been in business for at least four years, and can provide evidence of your successful track record,
you may apply to be a
Directory Only (DO)
Member of AdvoConnection.

If you are currently working as an advocate and can provide evidence of a track record of success,
you may apply to be a
Premium Member
of AdvoConnection.

If you represent an 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
DO Membership Plan

Learn more about the
Premium Membership Plan

Learn more about the
Business Membership Plan

DO Membership
dues are $129/year

Premium Membership
dues are $249 / year
(discounts available for some affiliations.)

Business Membership
dues are $699 / year for 5 advocates
(premium level)
plus a business listing
(6 listings total).
Additional advocates may be added for $150 each.

Not sure which of these memberships is right for you?
Find clarification here.

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? Contact us at: info (at) AdvoConnection.com
.................
Note: this application is long, and it can't be saved if you don't finish it.
Here's a copy of the application you can open to review before you begin filling it out.

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?

Directory Only
Premium
Business

We will 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:

What company is your advocacy/navigation business 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):

* 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
Pain Management
Geriatric / Eldercare or Home Health Services
Mediation (Helping families manage health-related disagreements)
Mental Health and Substance Abuse Assistance
Medical Bill Reviewing / 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.

Are you eligible for any membership dues discounts?

iRNPA
NAHAC
Other:

How did you hear about AdvoConnection?

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

This helps us reduce spam:

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.