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ACC Case Owner Hub

New Business On-boarding Form

Step 1 of 6

16%

Company Name(Required)

Business Location

Northland

Auckland

Waikato

Bay of Plenty

Gisborne

Hawke’s Bay

Taranaki

Manawatu-Wanganui

Wellington

Tasman

Nelson

Marlborough

West Coast

Canterbury

Otago

Southland

Please Select All That Applies

Your Name(Required)

First Last

Your Email(Required)

Key Contact's Name(Required)

First Last

Key Contact's Email(Required)

Key Contact's Phone(Required)

Services

Which services do you want included? Please refer to the proposal for details of each service. Tick all that apply.

Which PREVENTION SERVICES would you like included?

Group Training/Workshops

Job/Task Analysis & Risk Assessment

Functional Screens

Workstation Set Up Assessments

Workstation/Vehicle Audits

Which EARLY INTERVENTION SOLUTIONS would you like included?

Workstation/Worksite Assessments

Early Intervention in our Clinic

Telehealth

How many "Early Intervention in our Clinic" sessions do you pre-approve(Required)

3

6

Other

Which REHABILITATION SERVICES would you like included?

Return to work support (injury)

Return to work support (non-injury)

Would you like Physiotherapy for an injury claim included?

Yes

Any other services not listed you would like included?

Who in your business will be making referrals for TBI services?

Managers

Health and Safety Team

Our Staff

Others

Please specify

Reporting

For services where a report is included, who would you like the report to be sent to?(Required)

Referrer

Other

Name of person to receive report(Required)

First Last

Email of person to receive report(Required)

Equipment

Will your business pre-approve any equipment/consumable costs, such as splints, orthotics, strapping?(Required)

Yes. we will provide you with a maximum pre approved amount per employee

No. The provider needs approval before purchasing any equipment or consumables for the employee.

No. The company will not cover the cost of any equipment or consumables for the employee.

What amount do you pre-approve per employee?(Required)

Injury Claims

If the client has been referred for Early Intervention however our health provider considers that the client has definitely had a workplace injury – what do you want us to do?(Required)

Lodge the claim – and commence treatment under the Injury Claim

Seek further approval before lodging the claim form

Other (please state)

Other

Who manages your work injuries?(Required)

ACC

A Third Party Administrator

We self-manage

Do they also manage your non-work claims if the client opts in?(Required)

Yes

No

What’s the name of your Third Party Administrator?(Required)

If a staff member has a work injury, does the business cover the physiotherapy surcharge?(Required)

Yes

No, staff member must pay the surcharge

How many sessions are pre-approved?(Required)

If a staff member has a non-work injury, does the business cover the physiotherapy surcharge?(Required)

Yes

No, staff member must pay the surcharge

How many sessions are pre-approved?(Required)

If the clinician deems further physiotherapy would be beneficial following these maximum pre-approved sessions, is there scope to request additional sessions?(Required)

Yes. Please seek further approval before proceeding

Not applicable

No.

Please state what you would like us to do(Required)

Billing Details

How would you prefer to be invoiced?(Required)

Centralised Invoicing – all charges are invoiced on one monthly invoice (preferred method)

Individual Invoicing – 1 invoice per client at the end of the month

Other – please discuss with your TBI contact

Which email address should invoices be sent to?(Required)

Do you require a Purchase Order number or other reference on your invoices?(Required)

No

Yes (please provide purchase order)

Please provide purchase order(Required)

Do you want us to filter information about your Early Intervention service by branch locations and/or business department? This will help provide insights into referral and outcome trends.(Required)

No

Branch Locations (we will require list)

Departments (we will require list)

Both (we will require lists)

Branch Locations(Required)

Departments(Required)

How can TBI Health help you to roll these services out to your business? Tick all that applies

Meet with our local managers/reps

Provide us with resources to share with our managers/staff on the services and how to refer

Run an online webinar for key members of our team

Anything else?

Tell us about how we can help roll out these services