Fill and Sign the Arizona Workers Form

Attached is a medical report to support this Petition to Reopen. Dr.      Social Security No. *       Date of Injury:       ICA Claim No.:       Ins. Carrier Claim No.:                                                                                                                                                                                          INDUSTRIAL COMMISSION OF ARIZONA IMPORTANT: This completed form must be filed at an Industrial Commission ofArizona (ICA) office. (See addresses below.) The form must be accompanied by acurrent medical report supporting the reopening of the claim. PETITION TO REOPEN BASED ON NEW, ADDITIONAL OR PREVIOUSLY UNDISCOVERED DISABILITY OR CONDITION Copies of the Arizona Workers' Compensation Laws and Rules of Procedure and information about the ICA claims and hearing process are available at the ICA offices andthrough the ICA web-site located at: www.ica.state.az.us with a link to the Arizona Workers' Compensation Law and Rules of Procedure. Injured Worker VS. Defendant Employer Defendant Insurance Carrier Reopening is requested based on the new, additional or previously undiscovered disability or condition listed below related to this claim: 1. Check one of the following: or will submit a report to support this Petition to Reopen. 2. The following physicians have examined or treated me within the past two years for the conditions listed: DOCTOR'S NAME ADDRESS CONDITION AND DATE OF TREATMENT A. B. 3. I have worked for the following employers within the past two years. NAME ADDRESS JOB DESCRIPTION A. B. I have read this Petition to Reopen and the information contained is true and correct to the best of my knowledge. Signature of person or the person's authorized representative requesting reopening is REQUIRED. Date Address Telephone No. City State Zip Phoenix: Industrial Commission of Arizona Tucson Mailing address: P.O. Box 19070 Street Address: 800 W. Washington StreetPhoenix, Arizona 85007-2922 Office: Phoenix, Arizona 85005-9070 Industrial Commission of Arizona2675 E. BroadwayTucson, 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 FederalPrivacy 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 ofidentifying 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 birthdates, 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 placerendering 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 andphysician appointed by them to have, examine and/or copy any and all information, records and X-rays, regarding my physical condition and treatment. Signature of person or the person's authorized representative requesting reopening. Date Address Telephone No. City State Zip THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIALSERVICES AT (602) 542-1829. Form ICA 04-0528-83 (Rev. 6/00)