Request To Change Doctors {ICA 0121}

THE INDUSTRIAL COMMISSION OF ARIZONA CLAIMS DIVISION REQUEST TO CHANGE DOCTORS P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 INJURED WORKER: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 : COMPLETE NAME, ADDRESS AND TELEPHONE NUMBER: TO : COMPLETE NAME, ADDRESS AND TEL EPHONE NUMBER: PHONE #: PHONE #: DATE: INJURED WORKER The mand atory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Divisio n of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commis l security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund per taining 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 dis tinguished by the social security number. American LegalNet, Inc. www.FormsWorkFlow.com