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
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:
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