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Nazcare Training Inquiry
Click "Start" below to begin the form. Make sure to complete all questions before submitting!
7
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1
Full Name:
*
This field is required.
What's your Name?
First Name
Last Name
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2
Your Email:
*
This field is required.
Please include an email we can reach you at (double check for spelling errors before submitting!):
example@example.com
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3
Your Phone Number:
*
This field is required.
Please include a number we can reach you at:
Please enter a valid phone number.
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4
Are you enrolled in AHCCCS?
(if out of state from Arizona or you don't know, select No)
YES
NO
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5
Where do you currently reside? (City, State, and/or County)
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6
If you answered Yes to AHCCCS enrollment, which plan are you enrolled in?
Blue Shield - Ameriben
Arizona Physician's IPA - UHCCP
AZ HCare Cost Contain System - AIHP/AHCCS
Banner University Family - UFC/UCA
Care 1st
Health Choice of Arizona - HCA
Magellan Complete Care
Mercy Care RBHA
Arizona Complete Health (ACH)
Don't Know
n/a
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7
Do you have a case manager or are you receiving services from a clinic?
*
This field is required.
YES
NO
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8
Please provide the name and email of your case manager or the name of the clinic you're receiving services from.
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9
Lastly, do you prefer In-Person or Online training?
*
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In-Person
Online
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