GOV-026139 Appendix 1
Client’s claim number: [Claim number auto]
Purchase order number: [PO number auto]
[Date auto]
[Vendor name auto]
[Vendor_Address_Line1 Auto]
[Vendor_Address_Line2 Auto]
[Vendor_Address_Line3 Auto]
[Vendor_Address_Line4 Auto] [Post Code Auto]
Dear [ATTENTION TO auto]
We’d like to get your advice on a treatment injury claim
Client details
Client name:
[Client title auto] [Client full name auto]
Date of injury:
[Date of injury
auto]
Address:
[Additional Recipient Reference Auto], [Client address line 1 auto], [Client
address line 2 auto], [Client address line 3 auto], [Client address postcode
auto], [Client address country auto]
Date of birth:
[Date of birth auto]
Phone
[Client ph auto]
number:
ACC45
[ACC45 number auto]
NHI number:
[NHI no. auto]
number:
Injury(s):
[injuries auto]
To help us make a decision on [Client title auto] [Client full name auto]’s treatment injury claim,
we’d like you to provide External Clinical Advice (the Services).
We’ve got consent to request this information
[OPTION 1 START]The Injury Claim form (ACC45) that [Client full name auto] has already signed
gives us authority to collect this information.[OPTION 1 END]
[OPTION 2 START]We’ve included a copy of the authority for us to collect medical and other
records to help make a decision about this claim.[OPTION 2 END]
The services we’d like you to provide
We’ve listed below the service(s) we’d like you to provide, along with what we’ll pay you.
Service code  Service description
From
To
Qty.  Unit of
Rate per  Rate per
measure
unit, excl.  unit, incl.
GST
GST
[Service
[Service description auto]
[88/88/8888  [88/88/8888  [Qty  [Unit of
$[8888.88  $[8888.88
code auto]
auto]
auto]
auto]  measure
auto]
auto]
auto]
You can also invoice us for additional costs as described in the enclosed service schedule.
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GOV-026139 Appendix 1
[OPTION 1 START - if ECA01 approved]Please use the enclosed information to complete your
assessment and the ACC2187 Treatment Injury Advice form and send it back to us by
dd/mm/yyyy.[OPTION 1 END]
[OPTION 2 START - use if ECA02 approved]We’d like you to attend an advisory panel. We’ll be in
touch to provide more details about the time and location of the panel.[OPTION 2 END]
[OPTION 3 START - use if ECA03 approved]We’d like you to attend a review hearing in person /
by teleconference. Fairway Resolution Limited will arrange the review hearing with [Client first
name auto]. We’ll be in touch to provide more details about the time and location of the review
hearing soon.[OPTION 3 END]
Service requirements
Thank you in advance for filling out the external clinical advice report. Your prompt reply will help
us make a decision on this claim quickly.
If you’re unable to meet the timeframe, please cal me to organise a new time.
Please see below the service schedule for more details about what you need to know when
providing the service.
How to invoice us
You can invoice us using our online services. You just need to make sure that you include the
claim number, purchase order number and service code(s) shown on this letter.
If you’d like more information about how to send us your invoices electronical y, please get in touch
with the eBusiness team on 0800 222 994 option 1 or email [email address].
We’re here to help
If you’d like to talk about this letter or have any questions, please just get in touch with me using
the contact details below.
Yours sincerely
[Current User auto]
[Job Title auto]
Telephone: [INSERT phone number]
Encl. ACC External Clinical Advice Service schedule, [OPTIONAL]ACC2187 Treatment Injury
Advice template, [OPTIONAL]ACC6300 Authority to collect medical and other records
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GOV-026139 Appendix 1
ACC External Clinical Advice Service schedule
Please use the following payment schedule to invoice us:
Service
Service description
Rate per unit,
Rate per unit,
code
excl. GST
incl. GST
ECA01
Written report: including preparation and emails
$240.00 per hour  $276.00 per hour
ECA02
Attendance at a panel: including preparation
$240.00 per hour  $276.00 per hour
ECA03
Verbal advice: including signing off record of advice  $240.00 per hour  $276.00 per hour
DISBUR
Disbursements: such as phone calls, typing and
Actual and
Per item
copying, internet access and research, postage and  reasonable cost
courier
ECAT6
Other travel;
Actual and
Per trip
reasonable cost
Costs for return travel by ferry, taxi, rental car,
public transport and parking when:
•
return travel is via the most direct,
practicable route; and
•
the return travel exceeds 20km
Note 1: where the Supplier has no base or facility in
the Service provision area return travel will be
calculated between the “start point” and “end point”
closest to the client as agreed by ACC
Note 2: ACC will only pay for actual and reasonable
costs and receipts must be retained and produced if
requested by ACC. If more than one client (ACC
and/or non-ACC) receives services then invoicing is
on a pro-rata basis
ECATA1
Air travel when a Service Provider is:
Actual and
Per trip
•
reasonable cost
requested by ACC to travel to an outlying
area that is not the Service Provider’s usual
area of residence or practice to deliver
Services; and
•
air travel is necessary and has been
approved by ACC
Note: ACC will only pay for actual and reasonable
costs and receipts must be retained and produced if
requested by ACC. If more than one client (ACC
and/or non-ACC) receives services then invoicing is
on a pro-rata basis
ECATD10
Travel distance
$0.62 per
$0.71 per
kilometre
kilometre
A contribution towards travel:
•
for return travel via the most direct,
practicable route; and
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GOV-026139 Appendix 1
•
where the return travel exceeds 20km
Note 1: where the Supplier has no base or facility in
the Service provision area, return travel will be
calculated between the “start point” and “end point”
closest to the client (as agreed by ACC)
Note 2: ACC does not pay for the first 20km of travel
and this must be deducted from the total distance
travelled. If travel includes more than one client
(ACC and/or non-ACC) then invoicing is on a pro-
rata basis
ECATT5
Travel time - first hour
$120.00 per first
$138.00 per first
hour
hour
Paid for the first 60 minutes (or less) of total travel in
a day where:
•
the travel is necessary; and the Service
Provider travels via the most direct,
practicable route between their base/facility
and
•
where the services are provided; and the
distance the Service Provider travels
exceeds 20km return; and/or
•
the time the Service Provider travels
exceeds 30 minutes
Note 1: where the Supplier has no base or facility in
the Service provision area return travel will be
calculated between the “start point” and “end point”
closest to the client (as agreed by ACC)
Note 2: if travel includes more than one client (ACC
and/or non-ACC) then invoicing is on a pro-rata
basis
ECATT1
Travel time – subsequent hours
$240.00 per
$276.00 per
subsequent
subsequent
Paid for return travel time after the first 60 minutes
hour(s)
hour(s)
in a day paid under ECATT5, where:
•
the travel is necessary; and
•
the Service Provider travels via the most
direct, practicable route available between
their base/facility and where the services
are provided; and
•
additional travel time is required after the
first hour of travel
Note 1: where the Supplier has no base or facility in
the Service provision area return travel will be
calculated between the “start point” and “end point”
closest to the client as agreed by ACC
Note 2: the first 60 minutes must be deducted from
the total travel time and if travel includes more than
one client (ACC and/or non-ACC) then invoicing is
on a pro-rata basis
You’ll need to provide evidence of any costs you incur plus get prior approval from us for any travel by air,
bus or train. We’ll usually make the travel booking for you unless we agree to do otherwise.
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GOV-026139 Appendix 1
Things you should know when providing the service(s)
If the Service changes, we’l talk to you about the changes and agree in writing, which might be by
email. Along with the report we will own all the intellectual property in the materials you deliver to
us relating to the Services.
Your name will be in our decision letter and report so if you get contacted by the client or health
provider about the report, please direct them to ACC. It’s important you don’t enter into any
discussions with them about this.
Let us know immediately if you become aware of a conflict of interest at any time. If this happens
we ask that you return the request to us within five working days and we’l cancel it. The same
applies if you become aware of any issue relating to ACC, the Services and/or the purpose of this
letter which has or might have media or public interest.
For privacy reasons please make sure you keep all information about the client and your Services
confidential unless agreed to by ACC or required by law. Either of us may for any reason terminate
the Services on giving one weeks’ written notice to the other party without being liable to the other
party for any damages or compensation.
Acting as a Third Party Assessor
As an external clinical advisor you will carry out services in a competent and professional manner
and in accordance with all applicable legislation and professional standards, including the:
•
High Court rules in Part 9, Subpart 5 of the High Court Rules 2016: Expert witness to comply
with code of conduct (see
http://www.legislation.govt.nz/regulation/public/2016/0225/latest/DLM6951902.html) (with
appropriate modifications) Privacy Act 2020
•
Health Information Privacy Code 2020.
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GOV-026139 Appendix 1
ACC2187
Treatment injury advice
Use this form to provide advice to ACC on a claim for Treatment Injury. When completed please send your
report to the ACC Treatment Injury Centre.
Email: [email address]. Please send the email with “Treatment Injury Advice” in the subject header.
Mail: Treatment Injury Centre, PO Box 430, Dunedin 9054;
1. Client details
Client name: [Client title auto] [Client full name auto]
Claim number: [Claim number auto]
Date of birth: [DOB auto]
2. Request for external clinical advice – to be completed by ACC
Specific questions that ACC requires clinical advice on.
1.
2.
3.
4.
5.
3. Claim details – To be completed by external clinical advisor
Provide a summary of clinical events that led to the claim.
4. External Clinical Advisor response
Provide a response to the specific questions listed in section two and describe how the evidence supports
your conclusion. You’re welcome to include extra pages if you need to.
1.
2.
3.
4.
5.
ACC2187
May 2017
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GOV-026139 Appendix 1
ACC2187 Treatment injury advice
5. References
Provide a list of references to support your clinical advice.
6. External clinical advisor’s declaration and signature
If the Office of the Health and Disability Commissioner (HDC) requests a copy of this report, do you agree to
be named in the HDC report if your advice is quoted? (The HDC report may be published on the HDC
website.)
Yes
No
Signature:
Date:
Name:
Occupation/Speciality:
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.
ACC2187
May 2017
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Document Outline