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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
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  • Vocational Rehabilitation Referral

Vocational Rehabilitation Referral

Instructions

This form is to be used as referral for Special Fund’s Vocational Rehabilitation program.  The claim may be unscheduled with carrier involvement or scheduled claim where the injured worker is medically unable to return to work at time of discharge.  Carrier, self-insured, and/or TPA representative to complete the information requested on the form and submit pertinent medical data, such as operative reports and  medical supporting discharge from active care.  A complete file is not required.   

Sign and Submit Form

Vocational Rehabilitation Referral Form

Printer-Friendly Form

PDF icon 5528_SpecFund_Vocational_Rehabilitation_Referral_101517.pdf

Related Forms

Workers Supplemental Claim Form 413
Carrier's Notification of Scheduled Injury Time Loss
Workers Supplemental Claim For Compensation
Apportionment Settlement Letter
Vocational Rehabilitation Referral

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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