Fellowships not paid for by RAMQ (outside Quebec)

Physicians having done their pre-MD or postgraduate (residency) training in medicine in Quebec who do not obtain a fellowship position paid by RAMQ may not perform a fellowship in Quebec, even if they could receive a bursary or have the funds necessary to pay for their training. This rule stems from a government decree which stipulates that doctors having completed their pre-MD and/or postgraduate training in Quebec cannot obtain a clinical fellow card, which is mandatory for registration in a fellowship.

These doctors will therefore have to perform their fellowships in another province, the United States, or elsewhere. Note that the number of fellowships paid by the Ministry of Health and Social Services is not necessarily equal to the number of positions in university settings granted that year. It is therefore possible that, although you have obtained a position in an establishment’s PEM, you might have to perform your fellowship outside Quebec.

 

Some personal accounts

Fellowships available for terminating Quebec residents are limited, both in number and by specialty. For the past few years, medical residents wishing to undergo further training in certain leading-edge sectors after residency have chosen  to perform fellowships outside Quebec. In this section, we present tips and comments from a few of your colleagues who have performed or are about to perform fellowships elsewhere in Canada, in the USA, in Europe, and in New Zealand. The additional training chosen by these doctors is intended to open the way to a position in a university or non-university setting, depending on the requirements of the setting.

Detailed, more general information on additional training/fellowships outside Quebec is provided in the PEMs in SP section of the site.

 

Canada (outside Quebec)

Ontario

Fellowships performed in Canada, but outside Quebec, are either additional training or a second two-year training period, recognized by the Royal College of Physicians and Surgeons of Canada.

 

University of Toronto

Second training in Clinical Pharmacology and Toxicology

  • For access to a position for second training in a medical faculty in Canada, you have to submit your application via the postgraduate education program in which you are registered. Consult the program director, who will ensure follow-up internally.
  • In this case, the candidate was offered the position by his training site at the start of his R4 year.
  • After first performing a rotation in Toxicology at the Quebec Poison Control Centre, he wanted to carry out second training. So he proposed his approach to the site recruiting him, and it was accepted.
  • His application paralleled the CaRMS specialty matching process. Since this is training offered via the CaRMS process, he had to meet the same requirements and deadlines as for the medical subspecialty matching process, but without using the actual platform. This process was carried out in the fall of his R5 year.
  • The candidate received the support of an Emergency-Critical Care staff physician who had himself completed second training at the same university.
  • The support of another staff physician from the site recruiting him was also necessary for acceptance of the nature of the second training in the form of a fellowship.
  • The training was carried out to meet a special interest from the candidate and not in response to a specific request from the recruitment site.
  • An interview was conducted in person, but could have been carried out via Skype.
  • Pay for second training carried out in Canada is covered by the collective agreement of the body representing medical residents in that location, in this case the equivalent of an R6 and R7 with the Professional Association of Residents of Ontario (PARO). He thus enjoys the benefits of the PARO collective agreement, including work conditions, malpractice insurance, etc.
  • RAMQ covers healthcare (outside Quebec for studies). You just have to let them know. Healthcare services are reimbursable in all provinces, at RAMQ rates.
  • He also receives a bursary from the Quebec Association of Internal Medicine Specialists (ASMIQ).
  • No additional exam is required, since the fellowship will be performed in Canada and the specialty certification is recognized in every province.
  • To perform moonlighting in Ontario, a permit to practise in that province would be required.
  • The cost of housing in Toronto is rather high. Start looking 4-8 weeks before moving. Earlier is too soon. There is a fair amount of housing available.
  • Use of a car is not recommended. It is rarely needed in Toronto. Most hospitals are located downtown. A car is a nuisance rather than an advantage.
  • The candidate kept his Quebec driver’s licence.

McMaster University, Hamilton, Ontario

 

Fellowship in General Internal Medicine (Thrombosis)

 

  • The candidate for this additional training was approached by a group of internists from a university site that was recruiting. She discussed with them the site’s directions and orientations, and her interests, to see whether a fellowship could meet both parties’ needs. She is specializing in thrombosis. She then checked the best Canadian sites for performing this training, and applied to two places.
  • Help came from the head of department, who placed her in touch with a number of staff physicians who, in his view, could help her in her application process.
  • From there, she had to arrange things on her own.
  • Each fellowship is different, and sites do not have information on the procedure to be followed.
  • No prior rotation was required by the site in Ontario.
  • The interview was held on-site, but they would have agreed to conduct it via Skype. It is, however, important to check out the site in person, and the facilities, and to meet with the staff physicians, and possibly other fellows.
  • She initiated the process in the second half of her R4 year.
  • The candidate received a bursary from the site that will host her after her fellowship, and from the Quebec Association of Internal Medicine Specialists (ASMIQ).
  • She could also have worked as a clinical scholar at the university where she is performing her fellowship.
  • No supplementary exam is necessary, as certification in Internal Medicine and General Internal Medicine is sufficient.
  • permit to practise was obtained quickly through the College of Physicians and Surgeons of Ontario (CPSO).
  • Healthcare services are normally covered by the Quebec Health Insurance Board (RAMQ). The candidate also took out insurance with a Canadian firm associated with the FMSQ.
  • For bank accounts, she opened a chequing account and asked for an ATM card.
  • Housing is a complex element. She found an apartment, and an acquaintance living locally was able to visit it ahead of time.
  • The Quebec driver’s licence is accepted. Notably, she kept a residential address in Quebec.
  • car is needed in this setting, as public transit is not very efficient. Auto insurance is a puzzle, as coverage is province-based. Care has to be taken to take local insurance, and not for the entire province, otherwise she would have had to take an Ontario driver’s licence. She had to shop around a lot, and even then, she has to come back to Quebec with her car every 60 days to meet the terms of the insurance.

Sunnybrook Hospital, affiliated with University of Toronto

 

Fellowship in Radiology

 

  • The candidate applied in Canada for a fellowship in Abdominal Radiology.
  • These fellowships can be found at the following address: car.ca/membership/resident-section/fellowships.
  • The fellowship was intended to meet personal interests. No rotation in the new site was necessary. The candidate received no assistance from his training site.
  • The interview was conducted on-site.
  • He began the process at the end of his R3 year.
  • The candidate will receive a salary covered by Ontario medical residents’ collective agreement.
  • No additional exam and no application for a work visa were required.
  • Health insurance was confirmed with the hospital in Toronto.
  • No car. He uses public transit.
  • No bank account changes either.
  • Housing was found on www.condo.ca.

 

United States

One-year fellowship in Hematology-Oncology (Stanford University, California), followed by six months at University of Toronto

 

  • The procedures for confirming a fellowship in this discipline are very complicated.
  • There is little information on the subject.
  • His interests and the requirements of the site that will be hosting him were not standard training for the sites contacted for fellowships.
  • It is important to find out about requirements/equivalences and whether or not it is necessary to take the United States Medical Licensing Exams (USMLE).
  • He obtained a fellowship at Stanford University following an on-site interview.
  • For the fellowship in Toronto, the procedure was much simpler. The connection was made between a Quebec staff physician and a staff physician in Toronto. It all came together after an interview.
  • No prior rotation was necessary in either case.
  • The process began at the end of his R5 year, when the PEM in Quebec was confirmed, i.e., a year and a half before the end of his residency.
  • The choice of subspecialty met the requirements of both the site recruiting him and the candidate.
  • Pay in the USA will be via the facility. He will be paid as an R7. In Toronto, he will be paid from the Faculty’s research budget.
  • No additional exam was required.
  • Lots of red tape to be completed. The U.S. host university was very helpful in facilitating the process in the United States.
  • Health insurance is covered by the hospital, in the employment contract.
  • You still have to notify RAMQ of this period of time outside Quebec, because it usually pays part of the cost, i.e., the amount usually paid here for the same healthcare services.
  • The Quebec driver’s licence is accepted (considered valid) in the United States.
  • If you want to take your own car, you can do so. You can also have it shipped by rail or road, for about US$1,300 (2019) from Quebec to Stanford. But make sure no items for the move are left in the vehicle, otherwise another list of requirements will be added.
  • It is helpful to have a bank account in the USA, if only for transferring funds from your account in Quebec, or for other needs, such as housing. Open one as soon as possible after you arrive in the U.S.
  • For housing, it is hard to find anywhere furnished. Rents are very high (between $3,500 and $4,000 per month for a 3½). It is impossible to reserve ahead of time. The University always offers a waiting list, and expects to call you 1-2 months before you arrive.

 

Fellowship in Diagnostic/Abdominal Radiology

 

MD Anderson, University of Texas, Houston

  • The candidate, currently an R4 in Diagnostic Radiology, began the process in the spring of her R3 year, and the host site has already confirmed her fellowship. She points out that most Radiology residents had their fellowships confirmed by late in their R3 or early in their R4 year.
  • The candidate had applied for Interventional Radiology (Canada) and Abdominal Radiology (USA). After carrying out interviews, she opted for training in the U.S.
  • She received advice from colleagues who had taken such steps, in particular with regard to the University of California, Los Angeles (UCLA). Other colleagues told her about the U.S. site (MD Anderson) where they had done their undergraduate medical studies.
  • The choice of subspecialty related to the interests of the candidate, who wants to work outside Quebec.
  • She performed no rotation in the setting chosen for the fellowship
  • She did her interview in person.
  • The candidate will be paid by the U.S. hospital, and will have a J-1 visa. She will not be able to moonlight in the U.S. facility, but could do so in Canada during her vacation, for instance.
  • For the visa, she was told that the hospital offers help in that regard.
  • She had to take the United States Medical Licensing Exams (USMLE), and will have to sit the exam for the College of Physicians of the state concerned in June this year, i.e., one year before leaving for the fellowship.
  • For insurance and other services, she notes that the MD Anderson centre will pay for part of her health and dental insurance.
  • TD Bank has branches in the U.S., which make things easier on that front.
  • She will take steps to rent an apartment a few months before arriving in Houston.
  • The driver’s licence can be easily transferred to a Texas permit, but the fellowship will last only one year. She will lease or buy a vehicle in the U.S., and could bring it back to Canada after her fellowship.

 

Fellowship in Anesthesiology

 

University of California, San Francisco (UCSF)

  • The candidate is an R4, and has already confirmed her fellowship, which will run from August 2020 to August 2021.
  • The process involved sending an application along with all the associated documents (resumé, letter of intent, three letters of reference, all residency evaluations, and copies of the transcript from her undergraduate medical studies).
  • She heard from the person in charge one month later.
  • meeting was arranged in October 2018, during the American Society of Anesthesiologists annual meeting, being held in San Francisco. This meeting with the department head lasted two hours.
  • formal interview was then held in December 2018, at UCSFThe interview lasted 9½ hours. She met 10 people from the department for the subspecialty in question. She learned in January that her application had been accepted for 2020-2021.
  • In her view, an on-site meeting is much more worthwhile. It lets you get to know the site, sense the atmosphere, and meet the people with whom you will be doing the fellowship. Although this of course has a cost to it (flight, hotel, food), it is worth it.
  • She received no assistance from her training site.
  • For the choice of subspecialty, this corresponded to the interests of the candidate. She was interested in two subspecialties. She mentioned them to the site which offered her a PEM, and they chose one of them.
  • No prior rotation was required.
  • She started the process early in her R4 year.
  • The candidate will receive a bursary from her Quebec university. She was also be paid by the facility, since she will work there two days a week as a staff physician, and the other days as a fellow. So her fellowship will be self-financing.
  • She had to pass the Test of English as a Foreign Language (TOEFL).
  • The process for obtaining a work visa is still ahead.
  • All questions concerning personal services (insurance, bank account, etc.) will be dealt with a little later.

 

Fellowship in Emergency Medicine (Medical Toxicology)

 

New York University, New York

  • The choice of subspecialty was made following discussions with research groups, reading, and meetings at conferences throughout his residency. A mentor in his faculty also guided him in his search.
  • The candidate performed an on-site rotation to make a name for himself in the site.
  • He attended an on-site interview. The hospital was very accommodating concerning possible dates for this interview.
  • The fellowship application was made early in his R5 year, via the U.S. matching program.
  • Pay is similar to an R6’s, and corresponds to house staff salary.
  • No exam was required. This varies by program and specialty. Several of his colleagues decided to take the USMLE exam so as to have a regular permit to practise and be able to bill.
  • He applied for a J-1 Visa, as suggested by the host site. The procedure is quite simple. He had to get in touch with the Ministry of Health for a letter stating the need for this subspecialty, then gathered documents related to his residency, and submitted it all online to the U.S. State Department.
  • His spouse will accompany him on this adventure. She has hired a lawyer to help her obtain an H-2B visa, for the spouse of a J-1 visa holder. She will probably not be able to work with this visa. A number of friends have taken steps to obtain a TN visa, as professionals under the North American Free Trade Agreement (NAFTA), which allows the holder to work in certain industries.

 

Diagnostic Radiology, Abdominal Imaging and Interventional Services

 

Harvard University, Brigham and Women’s Hospital, Boston

  • The candidate is currently an R5 in Diagnostic Radiology.
  • He began the application process at the end of his R3 year.
  • He notes that he had the support of two staff physicians and his program director, who wrote letters of reference for his fellowship.
  • The choice of fellowship is based on his own interest but also on that of Quebec sites’ in this type of practice.
  • The candidate did not have to perform any rotations on-site, but did attend an interview there.
  • He will receive from the establishment a salary of approximately US$100,000.
  • He had no additional exams to take.
  • He will take the necessary steps to obtain a J-1 visa, supported by the U.S. establishment. His spouse will accompany him, and will also have a J-1 visa that will enable her to work.
  • More personal steps, such as opening a bank account, finding accommodation and so on, will be carried out a little closer to the departure date.

 

Vascular Surgery

 

Harvard University, Boston

  • The candidate has to do one academic year and one clinical year to be able to come back and work in the CHU de Québec network in his field.
  • The first year will be spent on a Master’s in Medical Education at Harvard Medical School. The path for this MMSc is quite simple. He just sent in an application and, after attending an interview, received his letter of acceptance last March.
  • He was helped by his program director in selecting the Master’s program, but handled most of the application process himself.
  • The subspecialty represented a personal interest for him.
  • He did not have to perform any rotations on-site.
  • He was interviewed via Skype.
  • He started the application process in his R4 year.
  • But he will be paid only during the second (clinical) year.
  • The only exam required was an English test (TOEFL).
  • At press time, the visa application process was still under way.

 

Europe

United Kingdom

Fellowship in Respirology, University of Oxford

 

  • Specialization in treatment of asthma and research.
  • Agreement in principle reached with the University of Sherbrooke.
  • To help in his steps to find a site, he contacted one of his mentors, a clinician investigator in the field, and an asthma specialist. It was recommended that he get in touch with researchers in the UK and the USA.
  • The candidate emailed the three researchers, with a cover letter, his resumé, and three letters of reference. All three researchers contacted him.
  • The candidate will go to do his fellowship with his spouse. The researchers contacted Human Resources themselves to see how the couple’s permits to practise/certifications could be recognized.
  • His spouse will be performing a fellowship in Psychiatry.
  • The UK was an easy choice, since the administrative procedure was simpler, and the academic approach was more attractive for both candidates.
  • The clinical and research orientation was the choice of the candidate and of the site hosting them after their fellowships.
  • No on-site rotation was necessary to confirm the fellowship.
  • The interview was conducted via Skype.
  • He began the process in the middle of his R4 year.
  • No salary or bursary is provided at the University of Oxford. The University of Sherbrooke Society of Physicians (SMUS) guarantees the salary of any professor going away on a fellowship.
  • The only exam required was the International English Language Testing System (IELTS) test.
  • Obtaining a work visa can be a difficult process.

 

France

Fellowship in Maternal-Fetal Medicine (Obstetrics and Gynecology), Bordeaux

 

  • The candidate has completed her residency and is already in practice.
  • The choice was made as a result of the expertise in the field in France, particularly with respect to obstetrical ultrasound.
  • The choice was tied to personal interests, but also to the requirements of her host site on her return.
  • She talked with a staff physician originally from France, who contacted his former colleagues, and two centres got back to him. She opted for Bordeaux University Hospital (CHU de Bordeaux), notably as it was easier to complete the administrative requirements there.
  • No prior rotation was necessary.
  • Discussions took place solely via email.
  • She began the process in the middle of her R4 year.
  • She applied for a training bursary to the Foundation of the establishment where she obtained a PEM. She also worked for a few months before going away on the fellowship, so as to accumulate enough money to pay for her stay abroad. Finally, she will none the less be receiving a small salary from CHU de Bordeaux.
  • No additional exam was required for obtaining the permit to practise.
  • Obtaining the visa was complicated, owing to the current master agreement for international cooperation. The legal framework is different, and this meant many discussions and email exchanges between the hospital in Quebec and CHU de Bordeaux. It is also complicated to determine which visa to apply for, as there are several options in France. Once the choice was made, though, and the documents submitted, the response was very rapid.
  • She took out personal health insurance via the FMSQ (Sogemec).
  • She took steps with RAMQ to maintain her eligibility despite being absent for more than 183 days. It is important to register with RAMQ to obtain a guarantee of this coverage. Although the absence is more than half a year, RAMQ continues to cover Quebec residents (give as your main address a permanent residence in Quebec), particularly in the case of study/further studies.
  • No car or driving licence needed.
  • Dealing with banks is a little complicated. But a bank account is needed to rent an apartment, to buy a cellphone package, and for a hospital ID card (you cannot register with Human Resources without a bank account).

IMPORTANT: Make an appointment with a bank before you arrive in France, before leaving Quebec, to ensure you deal with this aspect quickly and can carry out the other steps you have to take more easily.

  • The candidate found her housing by word of mouth. The easiest thing for those unable to do that is to go through an agency.

 

Other

New Zealand

Fellowship in Anesthesiology (Airway)

 

  • There is no standard pathway for fellowship positions in Auckland, New Zealand.
  • Candidates have to contact the hospital directly. In this case, for a fellowship in Anesthesiology, the candidate got in touch with a researcher in the field.
  • There are no paid positions.
  • He received a bursary from Laval University, but it does not cover all expenses associated with the fellowship.
  • The candidate got in touch with different hospitals over a three-year period, from the start of his R3 year, for this fellowship, but the most relevant one for him was given in New Zealand.
  • The interview was conducted via Skype.
  • No USMLE-type certification exam was required.
  • You just have to obtain a permit to practise from the Royal Australasian College of Physicians.
  • Spouses can accompany the candidate, and are allowed to work. Getting a work visa is easy.

 

Musculoskeletal Ultrasound

 

National Taiwan University Hospital, Taipei, Taiwan

  • The candidate’s residency was in Physical Medicine and Rehabilitation.
  • He practised for one year before starting his fellowship.
  • The fellowship was performed in the Physical Medicine and Rehabilitation Department.
  • After reading several scientific articles from that institution in his area of interest (Musculoskeletal Ultrasound), he went onto their Website and got in touch with them to find out whether it would be possible for him to perform a fellowship there that was a little longer than they usually offer.
  • He received no special assistance from staff physicians in his training site.
  • The choice of subspecialty was associated with a personal interest.
  • No prior rotation was necessary to confirm the fellowship.
  • He was interviewed on site while attending a conference being held there.
  • He began the application process at the end of his R5 year and on starting to practise.
  • He was paid through a bursary from the CHUM Foundation.
  • He did not have to take other exams to obtain a permit there.
  • To obtain the work visa, he went to the Taipei Economic and Cultural Office in Canada, in Ottawa, with the required documents (proof of fellowship, bursary, etc.) to obtain a 1-year visa.
  • His spouse accompanied him. She opted for a Youth Mobility (Working Holiday) Visa, available to Canadians aged 18-35 making their first long stay in Taiwan. Everything went very smoothly.
  • He opted for supplementary insurance from Blue Cross.
  • He sent his fellowship acceptance letter to RAMQ and obtained an extended period of health insurance coverage outside Quebec.
  • He notes that International Driving Permits (CAA) are valid in Taiwan, but only for one month. He takes public transit.
  • He opened a local bank account with his passport and visa.
  • He found accommodation quite quickly (less than two weeks)once he began looking.
  • He and his spouse took Mandarin classes before leaving, but this was clearly insufficient for acquiring a sound command of the language. It is said to take up to five years for that to happen. Fortunately, all interactions with colleagues at the hospital take place in English and, in his area of expertise, while the level of discussion was not very high with some patients, this was not a problem.

 

Nephrology/Home-based Dialysis

 

Princess Alexandra Hospital, Brisbane, Australia

  • The candidate completed her residency in 2018.
  • She completed a Master of Biomedical Science, Applied Clinical Research Option in fall 2018.
  • She left on her fellowship in February 2019.
  • She has a permit from the Collège des médecins du Québec, but it is currently inactive.
  • Her fellowship is in Home-based Dialysis.
  • She was particularly interested in this area of activity.
  • The site where she obtained her PEM also had a need in this regard.
  • staff physician who had performed her fellowship in the field recommended several locations to her for a fellowship.
  • She looked into the possibilities, and finally opted for Brisbane. She got in touch with the Brisbane team, who welcomed her with open arms.
  • The Brisbane administrative team assisted her in the fellowship and visa application process.
  • She points out that Australia is recognized for home-based dialysis.
  • The team she chose hosts numerous fellows from around the world.
  • She did not have to perform any prior rotations, or undergo an interview. She met the fellowship director at a Nephrology conference in November 2017.
  • The application process began during her R4 year.
  • She is not paid. But she received a competitive bursary from the CHUM, and a merit scholarship from the Société québécoise de néphrologie.
  • To get the Australian fellowship, she had to pass the International English Language Testing System (IELTS) assessment test.
  • The Subclass 407 Training Visa is the same whether a fellow is paid or unpaid. It allows you to practise in a clinic and conduct research.
  • To apply, you have to be sponsored by the hospital that will host you.
  • Before the application could be submitted by her host site, she had to have completed the process with respect to the Royal Australasian College of Physicians (RACP), the Australian Health Practitioner Registration Agency (AHPRA), and the hospital itself. This involved a criminal/police record check, recognition of the medical degree and residency (via the EPIC Portal), proof of vaccination, transmittal of a host of documents that had to be notarized as true copies, passing the English test, etc.
  • The process was so long drawn out that some documents had to be redone, such as the criminal record check, which is valid for only six months.
  • All documents in French have to be translated by a translator recognized by them, and this entails costs.
  • Once she received the sponsoring application from the hospital, she was able to complete her visa application. Documents concerning those accompanying her and proof of medical insurance for the duration of the stay were required.
  • A medical examination has to be carried out ahead of time, in a Montreal clinic recognized by Australia. (Blood and urine analyses, physical examination, and physician’s questionnaire, and chest x-ray.) This step cannot be completed in advance.
  • To obtain a permit to practise in Australia, you have to apply to the AHPRA, and this involves completing lengthy forms, providing numerous documents for recognition of educational credentials, administrative costs, and long lead times. She received her permit to practise a few weeks after arriving in Australia.
  • The red tape was time-consuming, challenging, and expensive. But it was worth it, in her view. The whole process cost $4,000.
  • The process can differ from one specialty to another.
  • She had her Internal Medicine diploma recognized, not her Nephrology diploma. She received a restricted permit which requires supervision and is tied to her host hospital. This type of permit has no impact on the practice permitted, but shortens lead times.
  • Her spouse accompanied her, and obtained a visa along with hers, as a dependant. This gives him the right to work in Australia in any field. But he is restricted to 40 hours’ work every two weeks.
  • The visa requires health insurance coverage. She dealt with a Quebec insurance agency, and her policy included a maternity clause in the event she became pregnant during her fellowship. Her insurance with Allianz costs her just under $1,000 a year, for coverage everywhere but the USA.
  • She is also covered by the Quebec Health Insurance Board (RAMQ), for 75% of her medical expenses, but calculated on the basis of what the same care would cost in Quebec. She just had to notify RAMQ before leaving.
  • She acquired an International Driving Permit. The process is very simple, and takes just a few minutes.
  • Before leaving, she opened an account in Canada with HSBC, which has branches in Australia. This allows her to make transfers easily, at advantageous rates. She was able to open her account in Australia as soon as she had a local address.
  • Before leaving, she also obtained bank authorization for her mother for her Canadian account, since her bursary is paid into her account here.
  • For housing, she used the Internet. She also contacted apartment buildings to find out about availability, and the documents needed for signing a lease. They visited an apartment right after they arrived, filled out the lease, and were accepted the next day. They moved in a week later. They had reserved an Airbnb ahead of time, to give them time to settle in.
  • She and her spouse bought a car right away, paying for it by bank transfer. Registration was completed directly by the car dealer. Auto and home insurance were very easy to obtain.
  • She agrees that a car is not a necessity on a day-to-day basis. The hospital and services are within walking distance. Public transit is also very efficient. The car is used to discover the surrounding region.
  • On the cellphone front, they took their Canadian phones and bought Australian (VODAFONE) SIM cards the day they arrived. They made the first payment with a Canadian credit card, and changed their contact information and payment method once they moved into their apartment.