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INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET PHOENIX,
ARIZONA 85007
(602) 542-4661
PETITION TO REOPEN BASED ON NEW, ADDITIONAL OR PREVIOUSLY UNDISCOVERED DISABILITY OR CONDITION
IMPORTANT: This completed form must be accompanied by a current medical report supporting the reopening of the claim. Copies of the Arizona Workers’ Compensation Laws and Arizona Workers’ Compensation Practice and Procedure and information about the ICA claims and hearing process are available at the ICA offices and through the ICA web-site located at: www.azica.gov


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ADDRESS
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ADDRESS


I have read this Petition to Reopen and the information contained is true and correct to the best of my knowledge.



Phoenix:
Mailing Address:
Industrial Commission of Arizona
P.O. Box 19070
Phoenix, Arizona 85005-9070
Street Address:
800 W. Washington Street
Phoenix, Arizona 85007-2922
Tucson
Office:
Industrial Commission of Arizona
2675 E. Broadway
Tucson, Arizona 85716-5342
*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 andbirth dates, and whose identities can only be distinguished by the social security number.


MEDICAL AUTHORIZATION


By this medical authorization or reproduction, I authorize and request each physician and person in the medical or related fields and each hospital, clinic, establishment or place rendering me any medical or related service to allow The Industrial Commission of Arizona or its authorized representative, my employer or its insurance carrier and each person and physician appointed by them to have, examine and/or copy any and all information, records and X-rays, regarding my physical condition and treatment.


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THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990 . IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT CLAIMS AT (602) 542-4661.


Form ICA 0528 - Rev 6/2019

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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