Claims Request to Change Doctors Form

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.