For referrals to support clients under the ACC Vocational Services Contract please use this link, otherwise please continue.ACC Vocational ServicesClient First Name*Client Last Name*Client Date of Birth* Client Phone No.*Client Email Address*Client Location*Are there any days or times during the week when the client is NOT be available for their initial appointment?* Yes NoPlease specify when the client is NOT available (e.g. Monday mornings)Note that restrictions may result in delays in scheduling the assessment.Employer*Referrer Name*Please selectSue WaltonEnviro WasteReferrer Phone No*027 210 4918Referrer Phone No*0800 RISK NZReferrer Email*sue@managecompany.co.nzReferrer Email*Envirowaste@managecompany.co.nzPurchase Order Number*Type of assessment required (select all required)*Clinic Physiotherapy (ACC Injury)Clinic Physiotherapy (EI – non ACC claim)Return to Work Plan/Support – non-ACC onlyClinic in the Cloud – Telehealth servicesWorksite Assessment for Pain or DiscomfortWorkstation Audit (no pain or discomfort)Other (please specify below)How would you like this Workstation Audit to take place? Face to face VirtualWhat is the address for the services to be delivered?Are there any health and safety risks the provider should be aware of when they visit the worksite? Yes NoPlease state health & safety risks.Is there any specific protective equipment or clothing the provider will need to bring to the visit? Yes NoPlease list protective equipment or clothing the provider will need.Maximum 3 sessions pre-approved for Clinic Physiotherapy (ACC Injury)Maximum 3 sessions pre-approved for Clinic Physiotherapy (EI – non ACC claim)Maximum 3 sessions pre-approved for Clinic in the Cloud – Telehealth servicesOther*Send Invoice To*manageaccpayables@managecompany.co.nzSend Report To*sue@managecompany.co.nzSend Report To*Envirowaste@managecompany.co.nzFile upload 1Max. file size: 256 MB.File upload 2Max. file size: 256 MB.File upload 3Max. file size: 256 MB.Additional Information
