Free THE INDUSTRIAL COMMISSION OF ARIZONA - Arizona

THE INDUSTRIAL COMMISSION OF ARIZONA
CLAIMS DIVISION
BRIAN C. DELFS, CHAIRMAN JOE GOSIGER, VICE CHAIRMAN LOUIS W. LUJANO, SR., MEMBER MARCIA WEEKS, MEMBER JOHN A. MCCARTHY, JR., MEMBER LAURA L. MCGRORY, DIRECTOR TERESA HILTON, SECRETARY P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 Claims Division: (602) 542 4661 Claims Division Fax: (602) 542-3373

INJURED WORKER:

REQUEST TO CHANGE DOCTORS

ICA CLAIM#: DATE OF INJURY: 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:

FROM:

DOCTOR'S COMPLETE NAME, ADDRESS AND TELEPHONE NUMBER:

TO:

DOCTOR'S COMPLETE NAME, ADDRESS AND TELEPHONE NUMBER:

PHONE #:

PHONE #:

INJURED WORKER'S SIGNATURE

DATE:

INJURED WORKER ADDRESS

INJURED WORKER'S 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 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.

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.

(Rev.12/08)

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.

(Rev.12/08)