Ariz. Admin. Code § R20-5-106 - Commission Forms

A. The following forms shall be used when applicable:

1. Employer's report of industrial injury (form 101) shall contain:

a. Employee, employer, and carrier identification;

b. Description of employment;

c. Description of accident and injury;

d. Description of medical treatment received by employee;

e. Employee's wage data;

f. Date, signature, and title of employer or the employer's representative; and

g. Statement doubting the validity of the claim, if the employer doubts the validity of the claim.

2. The physician's portion of the worker's and physician's report of injury (form 102) shall contain:

a. Name and address of physician;

b. Information regarding preexisting conditions;

c. Information regarding the industrial injury, treatment, and prognosis;

d. Statement authorizing the attachment of a medical report that contains the information required in form 102; and

e. Physician's signature and date.

3. Notice of supportive medical benefits (form 103) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Description of authorized medical benefits;

c. Date the notice is mailed;

d. Name and telephone number of the individual issuing the notice; and

e. Statement regarding reopening and appeal rights including filing requirements.

4. Notice of claim status (form 104) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Status of the claim;

c. Date the notice is mailed;

d. Name and telephone number of the individual issuing the notice; and

e. Statement of a party's hearing and appeal rights including filing requirements.

5. Notice of suspension of benefits (form 105) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Effective date of the suspension;

c. Reasons for the suspension;

d. Date the notice is mailed;

e. Name and telephone number of the individual issuing the notice; and

f. Statement of a party's hearing and appeal rights including filing requirements.

6. Notice of permanent disability or death benefits (form 106) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Applicable statutory authority under which compensation is paid;

c. Disability and compensation information;

d. Date the notice is mailed;

e. Name and telephone number of the individual issuing the notice; and

f. Statement regarding hearing and appeal rights including filing requirements.

7. Notice of permanent disability and request for determination of benefits (form 107) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Type of disability;

c. Applicable statutory authority for designated disability;

d. Designation of dependents where death is involved;

e. Designation of advanced payments and amount of the advance;

f. Date the notice is mailed; and

g. Name and telephone number of the individual issuing the notice.

8. Carrier's recommended average monthly wage calculation (form 108) shall contain:

a. Employee, employer, insurance carrier, and claim identification;

b. Employment and wage history;

c. Designation of dependents; and

d. Carrier's calculations for the recommended average monthly wage and the basis for the calculation.

9. Notice of permanent compensation payment plan (form 111) shall contain:

a. Employee, employer, and carrier identification;

b. Amount of permanent compensation and description of payment plan;

c. Name of the responsible entity contracted by the carrier to administer the payment plan;

d. Statement that the carrier remains the responsible party for payment;

e. Statement regarding supportive care and reopening rights;

f. Date the notice is mailed; and

g. Name and telephone number of the individual issuing the notice.

10. Report of insurance coverage (form 0006) shall contain:

a. Name and address of the carrier;

b. Legal name of entity that the carrier insures;

c. All other insured names or subsidiary entities under which the carrier's insured does business in Arizona;

d. Address of all insured entities with insurance policy information for each address; and

e. Employer Identification Number (EIN), Taxpayer Identification Number (TIN), or Federal Identification Number (FIN) assigned to each insured person or entity.

11. Report of significant work exposure to bodily fluids or other infectious material shall contain:

a. The requirements set forth in A.R.S. §§ 23-1043.02(B), 23-1043.03(B), and 23-1043.04(B);

b. Employee identification,

c. Employer identification,

d. Source of exposure person identification (if known),

e. Details of the exposure including:

i. Date of exposure,

ii. Time of exposure,

iii. Place of exposure,

iv. How exposure occurred,

v. Type of bodily fluid or fluids,

vi. Source of bodily fluid or fluids,

vii. Part or parts of body exposed to bodily fluid or fluids,

viii. Presence of break or rupture in skin or mucous membrane, and

ix. Witnesses (if known), and

f. Dated signature of employee or the employee's authorized representative.

12. The medical treatment preauthorization form (MRO-1.1) shall contain five sections, as follows:

a. Section I (Provider Request for Preauthorization) shall contain:

i. Injured employee identification, including name, date of injury, date of birth, and payer claim number (if known);

ii. Provider identification, including name, phone number, provider medical specialty, preferred method of contact, and contact information;

iii. Payer identification, including name and contact information (i.e., mailing address, fax number, or e-mail address);

iv. Information regarding requested medical treatment and/or services, including:

(1) Applicable diagnosis and/or ICD codes;

(2) A detailed statement of the treatment or services requested;

(3) Applicable Current Procedural Terminology (CPT) codes and/or National Drug Codes (NDC);

(4) Type of request (i.e., routine or urgent); and

(5) An indication as to whether the provider has attached documentation to support the medical necessity and appropriateness of the requested treatment and/or services; and

v. Dated signature or electronic signature of provider or provider's authorized representative.

b. Section II (Payer Decision on Request for Preauthorization) shall contain:

i. Payer's preferred method of contact and contact information;

ii. Date request for preauthorization is received;

iii. The Commission claim number;

iv. The payer's decision (i.e., approved, partial denial, denied, request for preauthorization incomplete, or IME requested);

v. An indication as to whether the payer has attached a statement of what treatment and/or services have been authorized, including, if applicable, a partial authorization, and, if the request for preauthorization is denied, in whole or in part, a statement of explanation that includes the medical reason supporting the payer's decision; and

vi. Dated signature or electronic signature of payer or payer's authorized representative.

c. Section III (Provider or Employee Request for Reconsideration of Payer Decision) shall contain:

i. An indication as to whether the provider or injured employee has attached a statement of the specific reasons and justifications to support the request for reconsideration;

ii. An indication as to whether the provider or injured employee has attached documentation to support the medical necessity and appropriateness of the requested treatment and/or services, if not previously provided; and

iii. Dated signature or electronic signature of provider, provider's authorized representative, injured employee, or injured employee's authorized representative.

d. Section IV (Payer Decision on Request for Reconsideration) shall contain:

i. Date request for reconsideration received;

ii. The payer's decision (e.g., approved, partial denial, denied, or IME requested);

iii. An indication as to whether the payer has attached a statement of what has been authorized, including if applicable, a partial authorization, and, if the request for preauthorization is denied, in whole or in part, a statement of explanation that includes the medical reason supporting the payer's decision; and

iv. Dated signature or electronic signature of payer or payer's authorized representative.

e. Section V (Provider or Employee Request for Administrative Peer Review) shall contain:

i. An indication of the basis for the request for administrative peer review (e.g., payer non-response, denial (in whole or in part) of requested treatment or services, the payer's decision on the request for preauthorization denied treatment or services that are subject to R20-5-1304(B));

ii. An indication as to whether the provider or injured employee has attached copies of relevant medical records and, if applicable, documentation related to the payer's non-response;

iii. An indication as to whether the provider or injured employee has attached all documentation and statements previously attached to Sections I-IV; and

iv. Dated signature or electronic signature of provider, provider's authorized representative, injured employee, or injured employee's authorized representative.

B. The following forms may be used:

1. The workers' portion of the worker's and physician's report of injury (form 102) requests:

a. Employee, employer, insurance carrier, and physician identification;

b. Description of the accident, including date of injury; and

c. Date and signature of the employee or the employee's authorized representative.

2. Worker's report of injury (form 407) requests:

a. Employee and employer identification,

b. Job title,

c. Employment description,

d. Employee's wage data,

e. Date of injury,

f. Accident and injury descriptions,

g. Medical treatment information,

h. Information concerning prior injuries of the employee,

i. Disability income, and

j. Date and signature of the employee or the employee's authorized representative.

3. Worker's annual report of income (form 110-A) requests:

a. Employee, employer, insurance carrier, and claim identification;

b. Employment and wage history for the preceding 12 months;

c. Date and signature of the employee or the employee's authorized representative attesting to the truthfulness of the employment and wage information; and

d. Statement that failure to submit an annual report of income may result in a suspension of benefits by the carrier or self-insured employer.

4. Notice of intent to suspend (form 110-B) requests:

a. Employee, employer, insurance carrier, and claim identification;

b. Employment and wage history for the preceding 12 months;

c. Date and signature of the employee or the employee's authorized representative attesting to the truthfulness of the employment and wage information;

d. Statement that failure to submit an annual report within 30 days of the date of the notice shall result in a suspension of benefits by the carrier or self-insured employer.

5. Request for hearing requests:

a. Names of the employee, employer, and insurance carrier;

b. Claim identification;

c. Identification of the award, notice, order, or determination protested and reason(s) for the protest;

d. Estimated length of time for hearing and city or town in which hearing is requested;

e. Name and address of any witness for whom a subpoena is requested; and

f. Date and signature of party or the party's authorized representative.

6. Petition to reopen requests:

a. Names of the employee, employer, and insurance carrier;

b. Claim identification;

c. Identification or description of the new, additional, or previously undiscovered temporary or permanent disability or medical condition justifying the reopening of the claim; and

d. Employee's medical and employment history.

7. Petition for rearrangement or readjustment of compensation requests:

a. Names of the employee, employer, and insurance carrier;

b. Claim identification;

c. Income and employment history;

d. Medical history; and

e. Statement of the basis for the increase or decrease in earning capacity.

8. Claim for dependent's benefits-fatality form requests:

a. Identification of dependent filing claim;

b. Identification of deceased;

c. Date of death;

d. Date of injury, if different than date of death;

e. Name and address of employer at time of deceased's death;

f. Statement of cause of death;

g. Names and addresses of health care providers rendering treatment to deceased in two years beforedeath;

h. Conditions treated by health care providers in the two years before deceased's death;

i. If claim is for spousal benefits, the form requests:

i. Name, address, and date of birth of spouse;

ii. Copy of marriage certificate;

iii. Date and place of marriage to deceased;

iv. History of prior marriages of deceased and deceased's spouse, including copies of divorce decrees; and

v. Statement of living arrangements at time of deceased's death, including reason for living apart at time of death, if applicable;

j. If claim is for a dependent child, the form requests:

i. Name, date of birth, and address of child at time of deceased's death;

ii. List of children in care and custody of current spouse; and

iii. Statement of whether unborn child is expected and date expected;

k. If claim is for dependent other than a child, the form requests:

i. Name and address of other dependent,

ii. Relationship of other dependent to deceased, and

iii. Statement of the nature and extent of dependency; and

l. Date, telephone number, and signature of dependent or authorized representative of dependent.

9. Request to leave the state form requests:

a. Employee, insurance carrier, and claim identification;

b. Reason for requesting to leave Arizona;

c. Dates leaving and returning to Arizona;

d. Out-of-state address;

e. Name and telephone number of attending physician; and

f. Date and signature of the employee or the employee's authorized representative.

10. Request to change doctors form requests:

a. Employee, insurance carrier, and claim identification;

b. Reason for requesting change of doctor;

c. Name and phone number of claimant's current doctor;

d. Name and phone number of doctor claimant requests to change to; and

e. Date and signature of the employee or the employee's authorized representative.

11. Complaint of bad faith and unfair claim processing practices requests:

a. Employee, employer, and insurance carrier identification;

b. Description of the alleged bad faith or unfair claim processing practices;

c. Date of the complaint; and

d. Name, address, and telephone number of the person signing the complaint.

12. Certification of employer's drug and alcohol testing policy requests:

a. Employer's certification as described under A.R.S. § 23-1021(F),

b. Name and federal identification number of the employer, and

c. Name of all subsidiaries and locations of the employer.

C. Optional use of a form described in subsection (B) does not affect any requirement under the Act or this Article.

D. Forms or format for the forms described in this Section are available from the Commission.

E. Forms prescribed under this Section shall not be changed, amended, or otherwise altered without the prior written approval of the Commission.

Notes

Ariz. Admin. Code § R20-5-106

Former Rule 6. Amended effective March 1, 1987, filed February 26, 1987 (Supp. 87-1). Amended effective August 28, 1992 (Supp. 92-3). R20-5-106 recodified from R4-13-106 (Supp. 95-1). Amended by final rulemaking at 7 A.A.R. 3966 and 7 A.A.R. 4995, effective August 17, 2001 (Supp. 01-3). Amended by final rulemaking at 15 A.A.R. 991, effective June 2, 2009 (Supp. 09-2). Amended by final rulemaking at 24 A.A.R. 2069, effective 10/1/2018.