GOV-027819 Attachment
ACC6246
Relevant documents list
The documents listed on this form are included with our request for a medical referral or assessment for this
client. Please refer to these documents when completing your assessment.
1. Client details
Client name: [Client full name auto]
Claim number: [Claim number auto]
2. Referral details
Referral to: [assessor name]
Date of referral:
3. Document details
Author
Document name (or description of contents)
Document date
Number
of pages
When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy
Code 2020. For further details see ACC’s privacy policy, available at www.acc.co.nz. We use the information collected on
this form to fulfil the requirements of the Accident Compensation Act 2001.
ACC6246
February 2015
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