Fill and Sign the Doctor Workers Compensation Az Form

INJURED WORKER:            DATE OF INJURY:       CARRIER CLAIM #:       SOCIAL SECURITY# :                                                 PHONE #-       DATE:       PHONE #-                         THE INDUSTRIAL COMMISSION OF ARIZONA CLAIMS DIVISION GAY CONRAD KRUGLICK, CHAIRMANMIKE PETCHEL, VICE CHAIRMANJEAN PIERRE ANGELCHIK, M.D., MEMBERSANDRA L. GRUNOW, MEMBERJAMES B. WHITTEN, MEMBER P.O. BOX 19070 KAREN ELLERMAN PHOENIX, ARIZONA 85005-9070 CLAIMS MANAGER(602) 542-4661FAX (602) 542-3373 REQUEST TO CHANGE DOCTORS LARRY ETCHECHURY, DIRECTORTERESA HILTON, SECRETARY ICA CLAIM #:PLEASE, BEFORE COMPLETING THIS FORM MAKE SURE THE DOCTOR YOU ARE REQUESTING TO CHANGE TO IS WILLING TO PROVIDE YOU WITH MEDICAL CARE UNDER YOUR INDUSTRIAL CLAIM. REASON FOR REQUESTING CHANGE OF DOCTORS: DOCTOR CHANGING FROM: DOCTOR CHANGING TO: INJURED WORKER'S SIGNATURE INJURED WORKER'S PHONE # ADDRESS CITY, STATE, ZIP CODE * 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 bySection 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 thesocial 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 SPECIAL SERVICES AT (602) 542-1829. (Rev. 5/00)