To enable us to check for eligibility for this service, please complete the following:Please confirmTeam member has a current ACC medical certificate for this injury(Required) Yes No* The team member may not be eligible for this service *Team member is receiving ACC weekly compensation(Required) Yes No* The team member may not be eligible for this service *Team member has been advised of this referral and agreed to this service(Required) Yes No* Please discuss this referral with your Team Member before submitting *I understand that all reporting is sent to ACC(Required) Yes No* Under the ACC Vocational Rehabilitation Services contract, all client reporting must be sent to ACC *Team 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 NameBooth LogisticsRegionPlease selectNorthlandAucklandWaikatoBay of PlentyGisborneHawke's BayTaranakiManawatu-WanganuiWellingtonTasmanNelsonMarlboroughWest CoastCanterburyOtagoSouthlandIs your company an ACC Accredited Employer? No Yes UnsureWho will be managing this claim? ACC Our TPA – please specify Our businessPlease specify your TPAPROVIDER NOTEPROVIDER NOTEPROVIDER NOTE – please contact genevieve.power@booths.co.nz 027 214 1585 and include her in the initial RTW meetingManager Name(Required) First Last Manager Phone(Required)Manager Email(Required) Referrer is the Manager Select if the Referrer is the ManagerReferrer Name(Required) First Last Referrer Phone(Required)Referrer Email(Required) Additional Information (e.g. current medical certificate status)Upload any documents here Drop files here or Select filesMax. file size: 256 MB, Max. files: 5.
