1149 GPs’ Guide to Completing the ACC45 Injury Claim Form
For a Sensitive Claim (as at July 2003)
Parts A,B & C:
45 ACC Injury Claim Form
Please also give previous surname if
changed in the past few years. Patient to complete
part a: personal details
Accurate name, address and date of
birth information enables ACC to link
new claims to previous claimant DAY MONTH YEAR
records. Check if this is a safe address for
NUMBER STREET NAME
ACC to write to.
ACC calls many claimants. Accurate
CODE CODE information assists in making contact
ACC collects ethnicity data to ensure quickly.
that it can provide services that are
part b: accident & employment details
If required, you can provide further information in answer to the following Please tick one box
questions on a separate sheet of paper
When did the accident happen – if Employers pay for work claims
exact date not known, the year will DAY MONTH YEAR TIME
(including claims for shareholder
be acceptable. employees).
(e.g. Taupo) Self-employed people pay for work
claims to the self-employed.
Please provide either Schedule 3 (see
over) event number or a description The government pays for claims from
of the incident/s. people who are not in employment.
Did the accident involve a moving motor vehicle
on a public road, driveway or beach?
Earners pay for non-work claims (e.g.
home, sport) from employees,
Occupation information helps ACC self-employed & shareholder
company in which I work
to estimate the impact of injuries on employees.
ACC needs this individuals in particular occupations.
information even if this
is not a work injury. The patient signature, in conjunction
The employer name & address is What is the address of the business with the patient declaration on the
required if the claimant needs time you are employed by/own ? reverse of the form, authorises the
off work. provider to lodge the claim with ACC
part c: patient decl aration and to release information to ACC
I have read and understood the important Patient Information and Patient Declaration on the reverse of the patient copy of this form. and its agents.
Patient to sign here
or legal guardian or representative 8 Date
DAY MONTH YEAR
Authorised representative’s Authorised representative’s
name relationship to patient Representative details must be given
The form must be signed and dated if signing for/on behalf of claimant.
before it can be accepted by ACC.
Parts D,E & F completed
Treatment Provider to complete
Note: ACC does not provide cover for illness or sickness. XX12345 Quote this ACC45 Claim Form
number if you call ACC about this
part d: injury diagnosis and assistance claim.
NHI Number, if known.
Please provide a diagnosis of the
mental injury that has arisen from the
Schedule 3 event. ACC requires one
or more diagnosis codes using Read,
ICD9 or ICD10 (please indicate which
one is used) or you may write the
diagnosis eg “depression”.
See the address on the back of this Has the patient been admitted to hospital?
form for Sensitive Claims.
Referral information (type of Treatment Provider referred to)
rehabilitation/assistance required Tick “Yes” if you want an ACC case
Tick “Yes” if the patient will need manager to call you about the claim.
further assistance from ACC such as part e: ability to work Registered Medical Practitioner only to complete this part
home help or case management. Tick
You only use the rest of this panel if
“No” if the patient just needs simple
the patient is unable to continue
medical or referred treatment without
normal work (i.e. can perform
other assistance from ACC.
DAY MONTH YEAR restricted duties or is fully unfit for
Please consider if the patient is able
to return to work on restricted duties.
If so, please indicate the number of
days and the nature of the restriction.
(Maximum 14 days using this form) DAY MONTH YEAR
Indicate whether the next event is a
If the patient does not want the DAY MONTH YEAR return to work or a follow-up visit to
employer to see this form due to the review the injury.
part f: treatment provider decl aration
nature of the information on it, you
I certify that, on the date shown, I have personally provided the services as specified Then give the date of that follow-up
may certify incapacity on a separate above and that in my opinion the condition is the result of an accident.
ACC 18 medical certificate. or expected return to work.
acc provider number
National Provider Index National Provider Index not yet
ACC Provider number, name, PROVIDER ID FACILITY AGENCY
signature & date must be completed Treatment provider
name (print) or stamp
before the form can be accepted Treatment provider 8
by ACC. signature Date
DAY MONTH YEAR
ACC or Accredited Employer copy: please return this form when completed to
your ACC Service Centre or to the Accredited Employer (check www.acc.co.nz). 03/03
If you require further assistance to complete this form, please call 0800 222 070