ACC Claim

Centered H3 Example

Physiotherapy Specialist Referral ACC Claim Form

Full Name (including Title)

Phone - Mobile Number

Patient Email address:

Patient work status:

CLAIM DETAILS: Note: If there are no remaining physiotherapy treatments on ACC45 claims, private fees will apply. ACC45's and ACC32's will not be completed for one-off assessments.

ACC Case Manager Name

Case Manager Contact Details (email or phone)

Would you like to attend the appointment by zoom?

Yes No

Would you like to attend the appointment in person with the patient?

Yes No

History and Treatment to date:

Referral Information

If this referral is for an ACC patient:

Please ensure there is an ACC claim with a Read Code that matches the body part being referred for assessment.
Please provide copies of any relevant clinical documentation for review before the appointment (specialist reports etc).
The "Private" fee will apply if there are no current ACC claim details provided.
Please forward written confirmation of funding for the appointment from the Insurer/Third party funder (if applicable).

THANK YOU FOR YOUR REFERRAL.

A FULL REPORT WILL BE PROVIDED WITHIN 7 DAYS OF THE CONSULTATION.

Physiotherapy Specialist Referral ACC Claim Form

Referral Information

Business Hours

Our Location

Contact Details

(03) 344 5394