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THE INDUSTRIAL COMMISSION OF ARIZONA
CLAIMS DIVISION

P.O BOX 19070
PHOENIX, ARIZONA 85005-9070
REQUEST TO CHANGE DOCTORS
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  = Required Information

Injured Worker Details

6/19/2019 ]

PLEASE MAKE SURE TO PROVIDE THE COMPLETE NAME, ADDRESS AND TELEPHONE 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 Details


Provider Details(From) DOCTOR'S COMPLETE NAME, ADDRESS AND TELEPHONE NUMBER

Provider Details(To) DOCTOR'S COMPLETE NAME, ADDRESS AND TELEPHONE NUMBER

Authentication Details

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* 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 Commission’s forms, prescribed under the Commission’s 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.


Claims ICA 0121-Rev 07.01.13
By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.

I agree


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