Patient Advocate Academy – Application Form
Complete this application to join our selective training program and start your patient advocacy career.
Section 1: Basic Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City & State
*
Preferred Method of Contact
*
Email
Phone
Text
Section 2: Background & Experience
Do you currently work in healthcare?
*
Yes
No
If yes, please describe your role and years of experience
Have you ever worked in patient advocacy, case management, billing, or a related field?
*
Yes
No
If yes, please explain your experience
What skills or experience do you have that would help you succeed in this program?
*
Section 3: Intent & Goals
Why are you interested in becoming a patient advocate?
*
Are you looking to start a business, work independently, or add this to your current role?
*
Start a business
Work independently
Add to current role
Other
What are your goals for the next 6–12 months?
*
What does success look like for you after completing this program?
*
Section 4: Readiness & Commitment
On a scale of 1–10, how committed are you to building this career/business?
*
Not committed
1
2
3
4
5
6
7
8
9
Extremely committed
10
1 is Not committed, 10 is Extremely committed
How many hours per week can you realistically dedicate to this program?
*
Are you willing to invest time into learning, implementing, and taking action?
*
Yes
No
What challenges (if any) could prevent you from fully committing?
Section 5: Financial Commitment
The Patient Advocate Academy investment is $297.
Payment options:
- Pay in full: $297
- Split payment option: $347 total ($50 added fee)
- First payment due within 7 days of acceptance
- Second payment due within 14 days
If accepted, are you prepared to make your payment within 7 days?
*
Yes
No
Which payment option would you prefer?
*
Pay in Full
Split Payments
Section 6: Alignment Check
What makes you a strong candidate for this program?
*
Why should we select you?
*
Is there anything else we should know about you?
Final Agreement (Required)
Submit My Application
Should be Empty: