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Resident/Fellowship Advocate Program
Please read this section before proceeding:
The Resident Advocate Program is no longer available to new clients.
Did you read the blue section above?
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Yes
No
Contact Information
First Name
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Last Name
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Birthdate
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+
Street Address
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Apt number
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number
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Personal email address
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Background Information
Are you married?
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Yes
No
Do you have children?
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Yes
No
How many children do you have?
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1
2
3
4
5
Are you a ?
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Medical Student - MS4
Resident
Fellow
Attending physician
Program Year:
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MS 4
PGY 1
PGY 2
PGY 3
PGY 4
PGY 5
PGY 6
PGY 7
PGY 8
Are you contributing to social security?
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Yes
No
I have no clue...
Do you plan on doing a fellowship?
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Yes
No
How many years is your fellowship training?
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1
2
3
4
Is your spouse also a resident/fellow?
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Yes
No
No, my spouse is an attending physician
How many years of training is your residency program?
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1
2
3
4
5
6
Name of Residency/ Fellowship Program
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What is your medical specialty?
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Abdominal Radiology
Addiction Psychiatry
Adolescent Medicine
Adult Reconstructive Orthopaedics
Advanced Heart Failure & Transplant Cardiology
Allergy & Immunology
Anesthesiology
Biochemical Genetics
Blood Banking - Transfusion Medicine
Cardiothoracic Radiology
Cardiovascular Disease
Chemical Pathology
Child & Adolescent Psychiatry
Child Neurology
Clinical & Laboratory Immunology
Clinical Cardiac Electrophysiology
Clinical Neurophysiology
Colon & Rectal Surgery
Congenital Cardiac Surgery
Craniofacial Surgery
Critical Care Medicine
Critical Care Medicine
Cytopathology
Dermatology
Dermatopathology
Emergency Medicine
Endocrinology, Diabetes & Metabolism
Endovascular Surgical Neuroradiology
Endovascular Surgical Neuroradiology
Endovascular Surgical Neuroradiology
Family Medicine
Family Practice
Female Pelvic Medicine & Reconstructive Surgery
Foot & Ankle Orthopaedics
Forensic Pathology
Forensic Psychiatry
Gastroenterology
General Dentistry
Geriatric Medicine
Geriatric Medicine
Geriatric Medicine
Geriatric Psychiatry
Hand Surgery
Hand Surgery
Hand Surgery
Hematology
Hematology
Hematology & Oncology
Infectious Disease
Internal Medicine
Internal Medicine-Pediatrics
Interventional Cardiology
Medical Genetics
Medical Microbiology
Medical Toxicology
Medical Toxicology
Molecular Genetic Pathology
Muscoskeletal Radiology
Musculoskeletal Oncology
Neonatal-Perinatal Medicine
Nephrology
Neurological Surgery
Neurology
Neuromuscular Medicine
Neuromuscular Medicine
Neuropathology
Neuroradiology
Nuclear Medicine
Nuclear Radiology
Obstetric Anesthesiology
Obstetrics & Gynecology
Oncology
Ophthalmic Plastic & Reconstructive Surgery
Ophthalmology
Orthodontist
Orthopaedic Sports Medicine
Orthopaedic Surgery
Orthopaedic Surgery of the Spine
Orthopaedic Trauma
Otolaryngology
Otology - Neurotology
Pain Medicine
Pain Medicine
Pain Medicine
Pathology-Anatomic & Clinical
Pediatric Anesthesiology
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology-Oncology
Pediatric Infectious Diseases
Pediatric Nephrology
Pediatric Orthopaedics
Pediatric Otolaryngology
Pediatric Pathology
Pediatric Pulmonology
Pediatric Radiology
Pediatric Rheumatology
Pediatric Sports Medicine
Pediatric Surgery
Pediatric Transplant Hepatology
Pediatric Urology
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Preventive Medicine
Procedural Dermatology
Psychiatry
Pulmonary Disease
Pulmonary Disease & Critical Care Medicine
Radiation Oncology
Radiology-Diagnostic
Rheumatology
Sleep Medicine
Spinal Cord Injury Medicine
Sports Medicine
Sports Medicine
Sports Medicine
Sports Medicine
Surgery-General
Surgical Critical Care
Thoracic Surgery
Thoracic Surgery-Integrated
Transplant Hepatology
Urology
Vascular & Interventional Radiology
Vascular Surgery
Do you have student loans?
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Yes
No
Does your spouse have student loans?
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Yes
No
Are you planning to try to get Public Service Loan Forgiveness?
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Yes
No
Not sure yet
What is your current student loan repayment plan?
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IBR
PAYE
REPAYE
Standard
Forbearance
Deferment
Other
What is your spouse's current student loan repayment plan?
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IBR
PAYE
REPAYE
Standard
Forbearance
Deferment
Other
What month and year did you start your current student loan repayment strategy?
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Expected annual income
Annual Income
2019
Annual Income
2020
Annual Income
2021
Annual Income
2022
Annual Income
2023
Annual Income
2024
Annual Income
2025
Annual Income
2026
Annual Income
2027
Annual Income
2028
Annual Income
2029
Annual Income
2030
Annual Income
Spouses expected annual income
Annual Income
2019
Annual Income
2020
Annual Income
2021
Annual Income
2022
Annual Income
2023
Annual Income
2024
Annual Income
2025
Annual Income
2026
Annual Income
2027
Annual Income
2028
Annual Income
2029
Annual Income
2030
Annual Income
How do you prefer to pay the RAP fee?
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Check
Credit card (separate payment email will be sent)
How did you hear of my services?
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Do you currently have disability insurance?
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Yes
No
Who is your disability insurance carrier?
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Guardian
Principal
MetLife
Northwestern Mutual
Ameritas
Standard
MassMutual
Other
Would you like a quote for disability insurance?
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Yes
No
Do you currently have life insurance?
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Yes
No
Would you a life insurance quote?
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Yes
No
What type of life insurance do you own?
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Term
Whole life
Universal life
Who is your life insurance carrier?
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Please list info for disability or life insurance quotes:
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Height
Weight
Do you smoke?
Your answer
Height
Weight
Do you smoke?
Please list any medical issues for the past 10 years including prescriptions, hospitalizations, and doctor visits:
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Please list any additional comments, concerns, or questions that you have for me.
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