Marlborough Osteopathy & Massage ACC CLAIM FORM

Please note

Your form will be checked by your practitioner and will be sent to ACC sometime after your consultation. Submission of this form does not lodge the claim directly to ACC

Patient Details
Optional (select not stated)
In paid employment in NZ?
Employment Details (if in paid employment)
Employer Details (if accident is work related, employer required)

Injury Details

Please find a sport in the auto-complete. Enter 'Not Obtainable' if sport is not listed
ACC's reason for collecting records

COLLECTING YOUR MEDICAL AND OTHER RECORDS

Why we ask for your authority to collect your medical and other records:

To establish cover and/or assess your entitlement to compensation, rehabilitation and treatment. We may need to collect medical and other records about you from a third party, such as your General Practitioner (GP), other medical professional, employer, or other government agencies. We need your authority to collect them.

We'll comply with the Privacy Act 1993, the Health Information Privacy Code 1994 and the Accident Compensation Act 2001 when collecting, using and managing personal information. You have the right to access any information we hold about you. You can also ask us to correct the information we hold about you. For more details see ACC's privacy notice at www.acc.co.nz/privacy.

These records could include:

  • medical reports
  • details of your accident
  • medical history relevant to your claim
  • specialist reports and assessments
  • your employment details and history
  • income and tax records.
In each case, we'd only seek records that are or may be relevant to your claim during the life of your claim.

SubmitKit's Privacy Policy