Accounting Self-Provider of Medical Benefits Form Instructions

An employer currently authorized by the Industrial Commission of Arizona to self-insure its workers’ compensation liability that is not a municipal employer, can choose to direct medical care for its injured employees pursuant to A.R.S. § 23-1070(A).

This form must be completed and filed regardless of whether or not the employer is directing medical care.  It provides the Industrial Commission with necessary information concerning whether the self-insurer is directing medical care for its injured employees.

If the employer chooses not to direct medical care, the employer must check the first box that states care is not directed.  If the employer chooses to direct medical care for its injured employees, the employer must check the second box indicating the employer directs medical care.

If directing care, this form must be accompanied by a detailed statement of arrangements pursuant to A.R.S. § 23-1070(B).  The detailed statement of arrangements aids the employee in understanding how the employer is directing medical care.  This statement must include a description of medical services available, with a description of how employees are informed of medical services available, how an employee obtains treatment from a specialty medical provider and where to receive prescribed pharmaceuticals.

If the employer has contracted services with medical providers, the employer must attach a copy of all contracts between the self-insured employer and the medical providers.  If the employer does not have contractual arrangements, the employer may submit a list of names and addresses of all medical providers with whom the self-insured employer utilizes to treat injured employees.

This form must be completed in its entirety.  Failure to do so may cause a delay in processing. It can be filed with the Industrial Commission Self-Insurance and Tax Office by mail or hand-delivery at the following address:

Industrial Commission of Arizona
Attn: Self-Insurance and Tax Office,
800 W Washington St, Room 301, Phoenix AZ 85007
Phone: (602) 542-1839
FAX: (602) 542-3070