To enable us to check for eligibility for this service, please complete the following:Please confirmDoes the employee have a current ACC medical certificate for this injury?(Required) Yes No* The team member may not be eligible for this service *Is the employee currently receiving ACC weekly compensation?(Required) Yes No* The team member may not be eligible for this service *Has the employee been advised of this referral and agreed to receive this service?(Required) Yes No* Please discuss this referral with your Team Member before submitting *I understand that reporting for this service is completed by TBI Health and provided to ACC.(Required) Yes No* Under the ACC Vocational Rehabilitation Services contract, all client reporting must be sent to ACC *Eligibility informationTo help us assess whether the employee may be eligible for ACC‑funded Return to Work support, please select all statements that apply: The employee is expected to be off work for more than 4 weeks, or their return to work is likely to be delayed The employee has previously attempted a return to work, but it was unsuccessful or not sustained The employee’s role is physically and/or mentally demanding and difficult to modify The injury is causing ongoing difficulties, and a return to work cannot be managed through simple duties or usual workplace support alone Other barriers to returning to work (please specify):Please specify barriersTeam Member's Name(Required) First Last Team Member's Date of Birth(Required) Team Member's Phone No.(Required)Team Member's Email(Required) Team Member’s Work Address(Required) Street Address Address Line 2 City Region Postcode ACC45 or claim number:(Required)Date of injury(Required) Select if date of injury is not known Select if date of injury is not knownDid the injury occur: At work Outside of work UnsureCompany Name(Required)RegionPlease selectNorthlandAucklandWaikatoBay of PlentyGisborneHawke's BayTaranakiManawatu-WanganuiWellingtonTasmanNelsonMarlboroughWest CoastCanterburyOtagoSouthlandIs your company part of the ACC Accredited Employer Programme (AEP)(Required) No Yes UnsureClick here for the list of Accredited Employers Find an Accredited EmployerWho will be managing this claim? ACC Our TPA – please specify Our business – we manage all our work injury claimsPlease specify your TPAManager Name(Required) First Last Manager Phone(Required)Manager Email(Required) Is the Manager the Referrer?(Required) Yes NoReferrer Name(Required) First Last Referrer Phone(Required)Referrer Email(Required) Our provider will coordinate an initial meeting with the client and the manager listed above. If you would like an additional person included, please select an option below.(Required) Not applicable Referrer listed above Other: Please specify.Additional Person's Name(Required) First Last Additional Person's Phone(Required)Additional Person's Email(Required) Additional Information or any other requests (e.g. current medical certificate status)Upload any documents here Drop files here or Select filesMax. file size: 256 MB, Max. files: 5.
