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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
    • Administration
      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
  • Home
  • Request to Change Doctors Form

Request to Change Doctors Form

Instructions

Any interested party or their authorized representative may petition the Commission for a change of doctors by filing this form.   This form must be completed in its entirety including the name, address and telephone numbers of the doctors.  Failure to provide this information may cause a delay in processing of the request. Make sure the doctor you are requesting to change to is willing to provide medical care under the workers’ compensation claim. 

IMPORTANT: If a request to change doctors is being made by an insurance carrier or self-insured employer because the treating doctor is not complying with the provisions of A.R.S. § 23-1062.02(C)(2), the party making the request should specifically state so on this form so that it can be processed accordingly. 

Sign and Submit Form

Request to Change Doctors Form

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PDF icon Claims_RequestToChangeDoctors_Master.pdf

Related Forms

Request for Hearing Form
Employer Report of Injury Form
Worker’s and Physician’s Report of Injury Form
Worker’s Report of Injury Form
Request to Change Doctors Form
Request to Leave State Form
Annual Report of Income Form
Notice of Intent to Suspend Form
Petition to Reopen Form
Petition for Rearrangement Form
Dependent Benefits Claim Form
Professional Employer Agreement Form
Bodily Fluids Work Exposure Form
Employee Rejection of Terms Form
Employee Revocation of Rejection of Terms Form

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