INDUSTRIAL COMMISSION OF ARIZONA
800 W WASHINGTON STREET
PHOENIX, ARIZONA 85007
(602) 542-4661

CARRIER’S REFERRAL FOR VOCATIONAL REHABILITATION

Carrier Details

From:

Claim Details

12/1/2020 ]

12/1/2020 ]

To:
The Industrial Commission of Arizona
Attention: Special Fund
P.O.Box 19070
Phoenix, AZ. 85005  

Forward with one copy of pertinent medical data, such as operative reports and medical supporting discharge from active care. A complete file is not required.

Claimant's Detail

Current Address:

Sex:

  
  

  
Employers Address:

  
Physician's Address:

Injury Details

Does Attending Physician recommend rehabilitation?
Did Injured worker return to work with the date of injury employer?


( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )

The Mandatory requirement that the social security number be included in forms filled 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,precribed 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 their birthdates, and whose identities can only be distinguished by the social security number.

THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATE FORMAT. CONTACT SPECIAL FUND AT (602)542-3294.

SpecFunds ICA 5528 -REV 10-15-17
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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