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Industrial Commission of Arizona

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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
    • Data & Statistics
    • 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
  • Home
  • Special Fund Carrier’s Referral for Vocational Rehabilitation

Special Fund Carrier’s Referral for Vocational Rehabilitation

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.   

Required Forms

Form Name Last Updated
Vocational Rehabilitation Referral 06/07/19
Vocational Rehabilitation Referral 06/07/19

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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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