Basic Information
Are you currently a member of EMRA?
Yes
No
First Name
MI
Last Name
Sex
Male
Female
Are you currently pregnant?
Yes
No
Date of Birth
What state do you currently live in?
Email Address
Preferred Contact Number
How did you hear about Integrated WealthCare
At what institution are you completing your training?
What is your current PGY status?
Are you currently moonlighting?
Yes
No
Will you complete your training within the next 12 months?
Yes
No
Do you have a signed contract?
Yes
No
Will you be working for
Hospital
Independent Contractor
Private Group
If you will be working for a hospital, please provide the name of your employer
What will your starting salary be?
Will you have long term disability benefits through your practice?
Yes
No
What are the benefits (will be expressed as a percentage of monthly income with a maximum monthly benefit)?
Will you be moving to a new state?
Yes
No
What State?
What is your anticipated date of transition?
During Medical School, residency or fellowship did you have any documented visits for stress, emotional trauma or other psychiatric evaluation?
Yes
No
Are you currently taking any anti-depressant medication?
Yes
No
Please provide relevant details:
Do you currently use, or have you ever used, tobacco products (including cigars, chewing tobacco and marijuana)?
Yes
No
Please provide relevant details
Do you have any bone or joint disorders that may be seen as medically relevant to an insurance company?
Yes
No
Plan Specifics: what is most important to you today?
How do you prefer to make your payments?
Annually
Semi-Annually
Monthly (auto bank draft)
Please provide any other data you feel is relevant or helpful to providing you the best solution.
Contact Information