ACC 45 Injury Claim Form

ACC45 ACC Injury Claim Form

Personal Details

Family Name

First Name(s)

Date of Birth

Gender

MaleFemale

Home/postal address

Street address

Suburb

City

Postcode

Telephone WORK

Telephone HOME

Accident and Employment Details

When did the accident happen?

Did the accident occur in New Zealand?

YesNo

Accident Scene

Accident Location

Describe how the injury happened

Is this injury a result of a motor vehicle accident?

YesNo

If sporting injury, name sport

Occupation

Please tick those that apply

I am in paid employment (part time or full time)I own/part own the company in which I workI am self-employedI am not in paid employment

What type of work do you do?

Sedentary (brief standing and walking)Light (mainly standing and walking)Medium (often lift 5kg plus)Heavy (often lift 9kg plus)Very heavy (often lift 22kg plus)

Did the accident occur at work?

YesNo

Name of the business you are employed by/own

Business Address

Street address

Suburb

City

Postcode

Patient Authorisation and Declaration

ACC DECLARATION

I DECLARE – The information I have given about this claim is true and correct and that I have not withheld any information.

I AUTHORISE – The treatment provider to lodge the claim for me. The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation,rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention I should receive. ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident.

Patient Signature

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(If under 16 must be signed by parent/guardian)

Date

Authorised representative’s name

Authorised representative’s relationship to patient

Injury Diagnosis and Assistance (Treatment Provider to complete)

ACC45 No.

Patient’s NHI No.

Diagnosis coding used if not READ Codes

ICD9ICD10

Diagnosis 1

Side

LeftRight

Diagnosis 2

Side

LeftRight

Diagnosis 3

Side

LeftRight

Is this a work related gradual process, disease or infection claim?

YesNo

Additional injury comments to injury code

Is this a claim for an injury caused by treatment?

Yes (Also fill in ACC2152)No

Has the patient been admitted to hospital?

YesNo

Referral information (type of Treatment Provider referred to)

Rehabilitation/Assistance Required (e.g. case management or home help)

YesNo

ACC should call me?

YesNo

Ability to Work (Registered Medical Practitioner only to complete this part)

Is the patient able to continue normal work?

Yes (skip to next section)No

Restricted Duties: The patient is able to undertake restricted duties

Additional restrictions

Fully Unfit: The patient is unfit for work for

Review/Return to Work: Based on this medical assessment

a review is required on, or the patient should be fit to return to normal work on

Treatment Provider Declaration

I certify that, on the date shown, I have personally examined the patient and that in my opinion the conditionis the result of an accident. I also certify that the patient (or their representative) has signed the Patient Authorisation and Declaration and has authorised me to lodge the claim on their behalf.

ACC Provider Number

Health Practitioner Index

Treatment Provider Name

Treatment Provider Signature

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Date