ACC 46

ACC Electronic Input Injury Claim Form

Patient to Complete


PART A - PERSONAL DETAIL

Surname

Street number and name

Suburb

Town/City

0

            Work

0

            Home

Please specify

PART B - ACCIDENT AND EMPLOYMENT DETAIL

(e.g. home, place of work, road)

(e.g. Timaru)

(e.g. rugby junior)

(part time or full time)

(tick one box only)

(brief standing and walking)

(mainly standing and walking)

(often lift 5 kg plus)

(often lift 9 kg plus)

(often lift 22 kg plus)

PART C - PATIENT DECLARATION AND CONSENT

Important Information

PATIENT You and ACC Working Together


This form is the first step in getting help from ACC if you've been injured in accident. ACC does not cover illness or a medical condition or conditions resulting from age degeneration. The form collects the basic information we need about your injury to help us decide if we can provide cover. If we need any more information about this claim we will contact you later.

ACC is here to help when you've suffered an injury. Once cover has been established (that means that you have an injury with ACC has accepted) we'll help towards the cost of your initial medical treatment, including GP costs, X-rays, physiotherapy, etc. This means it's important that all the information on this Injury Claim Form (ACC46) is accurate to make sure that you receive the right treatment and payments for this claim.

ACC will pay a fee direct to your treatment provider to your medical treatment. Your treatment provider may have charged you an extra amount (surcharge) above the amount that ACC can pay. We are not able to reimburse you for that surcharge.

ACC may be able to assist you with other types of help depending on your needs. But you must apply for this assistance. Please contact us on 0800 101 1996 to get our approval before you incur costs that you expect ACC to pay.

You can apply for the following types of assistance

  • Medical assistance, including medical treatment, dental treatment, further courses of treatment and travel to treatment.
  • Social rehabilitation assistance to help restore your independence, such as home help, childcare, attendant care, a wheelchair, home modifications and education support.
  • Vocational rehabilitation assistance to help you keep your job, find a new job or regain vocational independence. This support can include such things as assessment with finding a new job.
  • Financial assistance, such as weekly earnings compentation, or lump sum compentation.

If you whould like to know more about the claims process or any other ACC service, please call 0800 101 996


PATIENT DECLARATION & CONSENT


I declare:

  • that the information given in this form is true and correct and that I have not withheld any information likely to affect my application. I will inform ACC of any change in circumstances which may affect my entitlements

I autorise:

  • the collection and disclosure of any information about me to the extent necessary to determine cover and/or assess my entitlements to compensation, rehabilitation assistance, including medical treatment and/or the appropriate level if care and personal attention that I should receive, and/or to assist the evaluation of services and the performance of the ACC Scheme and/or to support the administration of the Health and Safety in Employment Act 1992.
  • the collection and disclosure of information for the purpose of research into injury preventation and affective assessment and rehabilitation
  • the treatment provider to lodge this claim for me

I understand:

  • that this authority relates to all aspects of my claim and authorises ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practioners, specialist, New Zealand Police, Occupational Safety and Health, treatment providers, IRD, Work and Income, assessment agencies, employers and withnesses to the accident).
  • that the information collected on this form will only used or disclosed in relation to the purpose od the Accident Compensation Act 2001.
    In the collection, use, disclosure and storage if information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code 1994.
  • that I have the right to see, and ask for the correction of, any information that ACC holds about me.
  • that this form may be used by accredited employers. In these cases, where ACC is specified in the patient declaration, this should be read as applying to the accredited employer managing my claim.

The information collected by ACC on this Injury Claim Form (ACC46) and at other times will be used to process this claim in accordance with the authority and understanding set out above, and in accordance with the Privacy Act 1993 and the Health Information Privacy Code 1994. The Privacy Act gives you the right to see and correct personal Information ACC holds about you.





04/07/2020