|The Industrial Commission of Arizona||
|Attention: Special Fund|
|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.
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