Azfmc

 If your provider is not already participating with the Arizona
Foundation for Medical Care
and you would like us to contact your provider’s
office to see if they will join our network, please complete the following information:

*Indicates a required field.
*First Name
*Last Name
Degree
Specialty
Practice Name
*Practice Phone
Practice Address:
Street
*City
State

    
Zip  

Tell us about yourself:
Your Name Your Phone
Your Email Cancel
    

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

//check phys first name
if (formObj.pfname.value==””){
formObj.pfname.style.backgroundColor=”#ffff99″;
check=false;
}else{
formObj.pfname.style.backgroundColor=”#ffffff”;
}

//check phys last name
if (formObj.plname.value==””){
formObj.plname.style.backgroundColor=”#ffff99″;
check=false;
}else{
formObj.plname.style.backgroundColor=”#ffffff”;
}

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

//check phys city
if (formObj.pcity.value==””){
formObj.pcity.style.backgroundColor=”#ffff99″;
check=false;
}else{
formObj.pcity.style.backgroundColor=”#ffffff”;
}

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