Arizona > Workers Comp
Request To Change Doctors - Arizona
| Request To Change Doctors Form. This is a Arizona form and can be used in Workers Comp . |
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THE INDUSTRIAL COMMISSION OF ARIZONA CLAIMS DIVISION JEAN PIERRE ANGELCHIK, M.D., CHAIRMAN P.O. BOX 19070 NOREEN THORSEN JAMES B. WHITTEN, VICE CHAIRMAN PHOENIX, ARIZONA 85005-9070 CLAIMS MANAGER BRIAN C. DELFS, MEMBER LOUIS W. LUJANO, SR., MEMBER For Information Call: JOE GOSIGER, MEMBER (602) 542-4661 FAX (602) 542-3373 LARRY ETCHECHURY, DIRECTOR TERESA HILTON, SECRETARY INJURED WORKER: ICA CLAIM#: REQUEST TO DATE OF INJURY: CHANGE DOCTORS CARRIER CLAIM #: SOCIAL SECURITY # *: PLEASE MAKE SURE TO PROVIDE THE COMPLETE NAME, ADDRESS AND TELPHONE NUMBER OF BOTH DOCTORS IN THE SPACE PROVIDED BELOW. FAILURE TO PROVIDE THIS INFORMATION MAY CAUSE A DELAY IN PROCESSING. IN ADDITION, MAKE SURE THE DOCTOR YOU ARE REQUESTING TO CHANGE TO IS WILLING TO PROVIDE YOU WITH MEDICAL CARE UNDER YOUR INDUSTRIAL CLAIM. YOU MUST SIGN THIS REQUEST. REASON FOR REQUESTING CHANGE OF DOCTORS: DOCTORS COMPLETE NAME, ADDRESS DOCTORS COMPLETE NAME, ADDRESS FROM : TO: AND TELEPHONE NUMBER: AND TELEPHONE NUMBER: PHONE #: PHONE #: D INJUREDWORKER S SIGNATURE DATE: INJURED WORKER ADDRESS IN JURED WORKERS PHONE # * The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commissions forms, prescribed under the Commissions Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH TH E AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT (602) 542-4661. (Rev.05/03) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 THE INDUSTRIAL COMMISSION COMPLIES WITH TH E AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT (602) 542-4661. (Rev.05/03) American LegalNet, Inc. www.USCourtForms.com
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