Last updated: 11/25/2025
Request To Change Doctors {ICA 0121}
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Description
ICA 0121 - REQUEST TO CHANGE DOCTORS. This form is issued by the Industrial Commission of Arizona (ICA) for injured workers under Arizona’s workers’ compensation system who wish to change their treating physician. The form requires the complete name, address, and telephone number of both the current and proposed doctors. Workers must provide a valid reason for the requested change and confirm that the new physician agrees to provide medical care under the industrial claim. The form must be signed by the injured worker and may be submitted electronically or by mail to the ICA for processing. Incomplete or unsigned requests may result in delays. www.FormsWorkflow.com
