Admin (ADM)

Below is a list of all the Admin forms available for submission using the Inbound Documents API.

Form / Document

Description

ACC001

Request for assistance for:

  • Boots, shoes, knee brace, back brace, compression/support stockings, insoles, heel raises, etc.Crutch Hire
  • Glasses, frames, cases, lenses, optometry eye examination, etc.
  • Mileage, taxis, accommodation, flights, etc.
  • Pharmaceuticals 
  • Treatment costs: CT scan, MRI scan, X-ray, GP consult, Physio, Acupuncture, Chiropractor treatment, injections, etc.
  • Wheelchair/scooter hire, walking stick, car parking, gym membership, meals on wheels, grocery delivery, lost wages, etc.
ACC003  Employee earning certificate
ACC004 Questionnaire for self-employed and shareholder employee
ACC009 / ACC9 Non-Acute Rehabilitation – Discharge Report
ACC038 Abatement / work hours form
ACC040 Termination pay information request - employer
ACC090 Review of Counselling Report
ACC100 Statement of financial position
ACC109 Request for time extension / Cover extension
ACC1152 Active Rehabilitation Report
ACC121 Is your injury work related questionnaire [Claimant]
ACC122 Is your employees injury work related questionnaire [Employer] - Vocational 
ACC1375 Transfer of care Notification
ACC1376 Interruption of care
ACC1378 Prior approval Notification to commence extend services
ACC1379 Request for Home Trial
ACC1564 Housing modification responsibilities
ACC1566 Tax options for backdated WC - Financial
ACC1584 Claimant identification register
ACC165 Declaration of Rights and Responsibilities
ACC167  Claimant authority for the collection of information
ACC176 Earnings certificate - Inland Revenue
ACC178 Consumables order form
ACC179 Nursing services notification
ACC180 Community nursing services - discharge summary
ACC188 Job details - employee
ACC191 Vocational Independence Assessment - File summary team review and quality check
ACC206 Work hours declaration
ACC207 Self-employed work tasks declaration
ACC210 Change of Bank Account Details or Address
ACC211 Direct credit request form 
ACC2126 Training for Independence Programme Completion Report
ACC2198 Asbestos cover questionnaire (non-fatal)
ACC2206 Asbestos cover questionnaire (fatal)
ACC2207 Incoming from GP or other Provider
ACC2208 Incoming from GP or other Provider
ACC2311 Mental injury questionnaire
ACC249 Pack - Request for reimbursement of pharmaceutical costs
ACC2537 Rabies post exposure treatment reimbursement funding request
ACC2610 Housing Modification - Handrail Referral
ACC263 Housing Modification Assessment Report - Minor Modifications - Vendor
ACC271 Medical practitioner cover questionnaire 
ACC272 Claimant cover questionnaire 
ACC273 Employer cover and work injury report 
ACC274 Work activities questionnaire - musculoskeletal gradual process claim 
ACC33 Independent review application
ACC34 Request to withdraw a review application
ACC359 Palliative Care Initial Clinical Team Assessment
ACC38 Abatement / work hours form
ACC4106 Social Rehabilitation 3-monthly declaration of Services Provided
ACC4203 Serious Injury Individual Support Plan 
ACC4232 Comprehensive Pain Assessment Report
ACC4233 Activity Focus Programme - Assessment Report
ACC4234 Activity Focus Programme - Progress Report
ACC4235 Activity Focus Programme - Completion Report
ACC4236 Activity Focus Programme - Non-Completion Report
ACC4249 Short-term Equipment (Needed Post Six Weeks Discharge) Request
ACC44 Statutory declaration
ACC4500 Serious Injury Individual Service Plan 
ACC4504 Serious Injury home & community support referral 
ACC4506 Determine Transport Needs
ACC5790 Consent For Communication Via Email
ACC5791 Declaration for the repayment of weekly compensation and reinstatement of leave
ACC5937 Authority to Act Form
ACC6173 Information Disclosure Checklist
ACC6179 Acknowledge receipt of information
ACC6220  Work Related Exposure Questionnaire - Client
ACC6221 Work Related Exposure Questionnaire - Employer
ACC6272 Pain Management Plan, Update and Completion Report
ACC6273 Pain Management Service Referral from a provider
ACC6300 Authority to collect medical and other records
ACC6301 Authority of Birth Mother to Collect Medical and Other Records
ACC67 Emergency Payment Details
ACC691 Vocational Independence Assessment Readiness Check
ACC705 Referral for Support Services on Discharge
ACC706 Early Notification of Complex Case
ACC709 Complaint letter from Client
ACC739  Inpatient rehab - extension of care
ACC7398 Request for further treatment
ACC74 Inpatient rehabilitation - Transfer of care notification 
ACC7412 Concussion Service child or adolescent referral
ACC7419 Training for Independence Request
ACC7422 Early cover application form
ACC7430 Stay at Work – Initial and Progress Report
ACC7431 Back to Work – Initial and Progress Report
ACC7433 Wheelchair & seating - progress and completion report
ACC7434 Social rehabilitation needs assessment – Integrated assessment report
ACC7685 Incoming from GP or other Provider
ACC7988 Concussion Service Direct Referral
ACC81 Social rehabilitation assessment referral
ACC84 How Would You Like Us To Pay For Your Care 
ACC86 Weekly Care Summary
ACC883 Concussion Service Referral
ACC884 Concussion service – client summary
ACC885 Concussion service – Did Not Attend (DNA) report
ACC904 Social Rehabilitation Integrated Assessment Report
ACC94 Vehicle puchase or modification responsibilities
ACC96 Equipment Order Form
   
Bank account details Claimant Payment details
Bank deposit slip Bank deposit slip
CD's  
Confirmation of claim withdrawal  Signed confirmation of claim withdrawal
Confirmation of Injury Diagnosis Confirmation of Injury Diagnosis from Provider
Death Certificate Death Certificate
GPSI Report GPSI Report from Provider
High Tech Imaging Radiology Reports
Home and Community Support Services Plan (HCSS) HCSS Service Plan/Progress Report
Medical Notes Medical Notes from Provider
Nerve Conduction Studies (NCS) Nerve Conduction Studies/ Electromyography
Neurological Assessment Neurological Assessment report from Provider
Neuropsychological Assessment Neuropsychological Assessment from Provider
NZ Post change of address card NZ Post change of address card
Order of Appointment of Welfare Guardian Order of Appointment of Welfare Guardian
Payslips Claimant Payslip
Photos Photos received 
Physio Notes Physio notes from Provider
Power of Attorney Letter from Advocate RE: Power of Attorney 
Pre-Employment Preparation Pre-employment Preparation Programme Plan
QAMs Docs  
Request to Fund Nerve Conduction Studies Request to Fund Nerve Conduction Studies/ Electromyography
Section 103 Assessment Section 103 Assessment from Provider

 

Available from September 2023.

Form / Document

Description

ACC345

Education Support Assessment Report