Azfmc

If you are interested in an Arizona Foundation for Medical Care plan to cover yourself, your family, or your employees please enter the requested information below.
Please note that this is an Arizona-only network of providers.

Information provided is solely used to contact you with healthcare options.
*Indicates a required field.
*Plan: Individual
  
Family
  
Group  


     *number of employees:
*Name:
*Email:
*Phone: (daytime)
Call Me: to
   
Any Weekday
Monday
Tuesday
Wednesday
Thursday
Friday

Address:
Street
City State Zip
            *How did you hear about us?
 

Please Choose One:
Physician
Family Member
Friend
Previously Had an Arizona Foundation Plan
Mayo Clinic
Advertisement/Publication
Web Site
Other

   If other, please specify in Comments.
Comments:
Cancel     

function hideshow(){
if (document.ncform.plantype[2].checked==true){
document.ncform.numemp.style.visibility=’visible’;
document.getElementById(’employ’).style.visibility=’visible’;
}else{
document.ncform.numemp.style.visibility=’hidden’;
document.getElementById(’employ’).style.visibility=’hidden’;
}
}

hideshow(); //run once when the page loads

//document.ncform.plantype[0].checked=true;

//just curious
//document.ncform.cname.style.backgroundColor=”#ffff99″;

function filledout(formObj){
//checks to see that all required fields have data, but does not validate data
var check=true;

//check the plan type
if (formObj.plantype[0].checked==false && formObj.plantype[1].checked==false && formObj.plantype[2].checked==false){
formObj.plantype[0].style.backgroundColor=”#ffff99″;
formObj.plantype[0].style.color=”#ffff99″;
document.getElementById(‘radio1’).style.backgroundColor=”#ffff99″;
check=false;
}

//check the number of employees
if (formObj.plantype[2].checked==true && formObj.numemp.value==””){
formObj.numemp.style.backgroundColor=”#ffff99″;
check=false;
}

//check name
if (formObj.cname.value==””){
formObj.cname.style.backgroundColor=”#ffff99″;
check=false;
}

//check email
if (formObj.email.value==””){
formObj.email.style.backgroundColor=”#ffff99″;
check=false;
}

//check phone
if (formObj.phone.value==””){
formObj.phone.style.backgroundColor=”#ffff99″;
check=false;
}

//check how learned
if (formObj.howlearned.selectedIndex==0){
formObj.howlearned.style.backgroundColor=”#ffff99″;
for (loop=0; loop < formObj.howlearned.options.length; loop++){
formObj.howlearned.options[loop].style.backgroundColor="#ffff99";
}
check=false;
}

if (check==false){
alert ("You missed one or more required fields.");
return false;
}else{
return true;
}
}