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Would you prefer that we contact you?

Fill out the form below during regular business hours, and you will receive a call back from one of our BETE staff ready to help you.

Your Name:

Your Relationship to the Person Needing Benefits/Care: --None--Spouse Partner Parent Child Physician Other Self

Client (who is in need of benefits/care?):

Email:

Phone:

Would you prefer to be contacted by phone or email: --None-- Email Phone

In what county does the person needing care reside?: --None-- Maricopa Apache Cochise Coconino Gila Graham Greenlee La Paz Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Other

In what type of setting are they currently?: --None-- Home Nursing Home Assisted Living Other

In what benefits are you interested?: --None-- Healthcare Questions Eligibility Concerns Other Questions or Concerns

How Can We Help You?: