My Care Coach™ Advocate Application
Thank you for your interest our new program.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please share your number if it is OK to call you.
Format: (000) 000-0000.
Your professional background
Please check all that apply to you.
*
BCPA
CSA
Carry business insurance
Listed in the GNA directory
Active in business as a patient advocate/closely related role
Other
Other professional credentials related to patient advocacy (optional):
Please list those that most people would likely recognize, i.e. RN/BSN, not FAAN.
How many years have you worked as a Patient Advocate or in a closely related role?
*
Less than a year
1 - 2 years
3 - 5 years
6 10 years
More than 10 years
Your Areas of Expertise
Please select up to 4 areas where you have deep professional expertise and would feel confident coaching clients on related major concerns.
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Understanding diagnoses, medical decision support
Care coordination and healthcare navigation
Insurance, billing and financial navigation
Hospital care, discharge and transtions of care
Differently abled healthcare support, resources
Medication management, polypharmacy
Aging care, transitions in living (AI, memory, LTC)
Family caregiver support/resources, Medicaid, VA benefits
Pediatric and family care
Serious illness and advanced care planning
Patient rights, communication and conflict resolution
None of the above: prefer to be a generalist
My area/s of expertise not listed, will describe in the next section
Your Expertise in Medical Conditions (optional)
Please select any medical conditions in which you have deep knowledge.
Blood disorders
Cancer
Diabetes
EDS, POTS, Ehlers-Danlos, Mast Cell Activation Syndrome, autoimmune
Gastrointestinal
Heart disease
Joint replacement
Kidney, Liver disease
Mental health
Neurologic (TBI, Alzheimers, Lewey Body, FTD, stroke, other neurological conditions
Organ Transplant
Parkinsons
Pulmonary diseases
Other
Additional Information You'd Like to Share
Please describe any other in-depth experience you have.
Please list in bullet points, or numbered list.
What other needs or skills (in general) should we know about?
Submit
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