ACC32 Treatment Extension Request

Complete this form to request and validate ongoing treatment on behalf of a patient, or to request an alteration in diagnosis. The request must relate to an injury that has an accepted ACC claim. If you require any technical support with this form, please call us on 0800 222 994 option 1. To check claim status, go to https://health.myacc.co.nz/portal/secure/ebusiness/invoicing/query-claim-status
Provider Type
This is required.

Reason for Request

Additional treatments
This is required.
Add or change a diagnosis or side
You are unable to change the diagnosis
This is required.
This is required.
This is required.
Please choose one 'Yes' option.

Patient Details

The claim number is required. Please enter a valid claim number.
/ / Please enter a valid date This date is in the future
This is required.
/ / Please enter a valid date This date is in the future
/ / Please enter a valid date This date is in the future
A first name is required.
A last name is required.
The patient address is required.

You can select read codes in this list that are within your scope of practice only (which hasn't changed) to add or change a diagnosis.
Note - If the code you wish to select (within your scope) is not in this pre-populated list, simply manually enter the code in this text box and you will be prompted for supporting information as part of our 'non-standard' process.

Add READ Codes (up to 6)
This is required.
Change a side of READ Codes (up to 6)
This is required.
Lodgement Errors (up to 3)
E.g. Lodging provider incorrectly coded an ankle sprain, when the correct code should be a lumber sprain.
Characters left:
This is required.
Please supply at least one of READ code options

Treatment Request Details

This is required.
This is required.
This is required.
PT01 and PT05 treatment numbers are invalid, both can't be set to the same value.
This is required.
This is required.
This is required.
$
This is required. The maximum amount is $999.99.
Please complete at least one number of treatments.
This is required.
/ / This date is more than a week ago Please enter a valid date

Current Status and Prognosis

Please provide more information because:
  • Cost of splinting the hand is more than $300 excluding GST.
  • The injury, or related surgery, occurred more than 12 months ago.
  • This is not the first request for additional treatment.
  • This injury is not in the standard read code list.
  • This is a lodgement error.
  • This is a voluntary request.
Characters left:
This is required.
Include a precise description of the current condition and if appropriate, why the current diagnosis differs from the original injury:
Characters left:
This is required.
A causal link needs to be established for ACC to consider if the condition requiring treatment is related to the covered injury.
Characters left:
This is required.
Characters left:
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  1. Characters left:
    This is required.
  2. Characters left:
    This is required.
  3. / / This date is more than a week ago Please enter a valid date
For example, onward referral, investigation.
Characters left:
This is required.
UPLOAD – 10MB limit per attachment (maximum is 6 files).
Files to Upload
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File too large: max 10MB Cannot upload this file type This is required.

Provider Details

This is required.
The ACC provider ID number is required. Please enter a valid ACC provider ID number.
This is required.
The ACC vendor ID number is required. Please enter a valid ACC vendor ID number.
A phone number is required. A valid phone number is required

Summary


Please check the details below before submitting. You can go back and edit if needed.

Reason for Request Patient Details Add or Change a Diagnosis or Side Treatment Request Details Current Status and Prognosis Provider Details
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Declaration of discussion with patient

I have discussed with my patient:

  • that the information (including personal details) on this form is true and correct.
  • that they are taking personal responsibility for their rehabilitation and treatment, and will actively participate in this treatment plan that has been developed.

My patient has authorised:

  • the collection of medical and other records which are or may be relevant to the provision of further treatment on this claim.
  • me to lodge this request for treatment on their behalf, and understand that funding for further treatment is subject to prior approval by ACC
  • ACC to update their claim record with the postal address on this form if it differs from the one already held by ACC.

Provider declaration

  • This treatment is for the personal injury for which the patient has cover.
  • The treatment is for the purpose of restoring the patient’s health to the maximum extent practicable, and is necessary, appropriate, and of the quality required for this purpose.
  • I have discussed the treatment options with the patient and advised why the recommendation is the appropriate treatment in this case.
× You have successfully submitted the form.

Confirmation

Thank you for your request.

We will review your ACC32 request and endeavour to be in touch with an approval, decline or request for more information within 10 days.

If you have any questions about your request or the ACC32 process in general, please phone the ACC Provider Contact Centre on 0800 222 070 (7am to 7pm Monday to Friday) and select 'option 4', or email provider.help@acc.co.nz.

Kind regards

ACC32 Team

What would you like to do next?

Patient Details Provider Details Reason for Request Add or Change a Diagnosis or Side Treatment Request Details Current Status and Prognosis Declaration

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If you require any technical support with this form, please call us on 0800 222 994 option 1.