Vocational Medical Services - named service provider

What you need to fill out this form

Before you start, please ensure you have the following:

  • the name and the email address for the supplier you are applying to work for
  • the vendor ID for the supplier you are applying to work for
  • an up to date CV for yourself
  • your health provider index number (if known)

When you have all the relevant information, please allow around 15 - 20 minutes to enter it, as the form can’t be saved.

If you have questions regarding this form, or would like to know more about this service, contact us.

Email MedicalAssessments@acc.co.nz

Your privacy

We know your privacy is important to you. Handling your information with care and respect is important to us, too. To understand how we handle your personal information, read our privacy notice. 

Our privacy notice

Your details and your supplier details

We need details of the supplier for the supplier you are applying to work for, as well as details for you ('the provider').

Please include your full name
Do you have a current ACC provider number?
This is your Health Provider Index (HPI) number

Complete ACC24

You will need to complete an ACC24 form, as part of your application. Click the link below for this form to open in a new tab on your browser. 

Complete ACC24 online

The geographic area(s) you will provide face to face services in
Northland Territorial Authority (TA)
Auckland Territorial Authority (TA)
Waikato Territorial Authority (TA)
Bay of Plenty Territorial Authority (TA)
Gisborne Territorial Authority (TA)
Hawke’s Bay Territorial Authority (TA)
Taranaki Territorial Authority (TA)
Manawatu-Wanganui Territorial Authority (TA)
Wellington Territorial Authority (TA)
Nelson/ Marlborough Territorial Authority (TA)
West Coast Territorial Authority (TA)
Canterbury Territorial Authority (TA)
Otago Territorial Authority (TA)
Southland Territorial Authority (TA)
Do you have vocational registration?
Do you hold a:

If you meet the following conditions, please answer the question below.

  • You are a General Practitioner (FRNZCGP)
  • You are registered with the New Zealand Medical Council within the General Practice vocational scope
  • You hold a current Annual Practising Certificate
Services to be provided
Do you have a minimum of five (5) years general practice experience and demonstrated relevant and current work experience in disability management in the workplace or in occupational rehabilitation

ACC is committed to supporting a meaningful and sustainable advancement towards cultural safety and improved health outcomes and experiences.

Cultural Safety is acknowledging differences between groups and addressing biases that may impact on the quality of health and rehabilitation services, access to those services or the equity of health and rehabilitation outcomes.

Cultural Competence is having the attitudes, skills, and knowledge to function effectively and respectfully when working with and treating people from a range of cultural backgrounds. 

This may be special interests or expertise (eg TBI, Sensitive Claims, rural community etc), ethnicity, gender or any other attributes.
Are you a Vocational Trainee in Occupational Medicine?
Are you currently an active trainee with Australian Faculty of Occupational and Environmental Medicine (AFOEM)
Current Stage of training (Stage B and holding relevant Occupational diploma will be considered)
Relevant postgraduate qualification in occupational medicine completed
Please select from below, supervision is provided:

Complaints

Have you as the Named Service Provider currently or at anytime in the last five (5) years, as an individual or as part of a practice, been the subject of a complaint made to the Health and Disability Commissioner, the Police or a Professional Body or a fraud investigation in New Zealand, Australia, or the Pacific Islands?

Based on the above, have you been subject of a complaint?
(please state if the outcome (decision) is pending and the expected due date)

De-registration / Termination

As the Named Service Provider, have you ever been de-registered as a Provider or terminated from a contract with ACC or any other government agency as a result of a complaint or adverse findings as either a Supplier/Vendor or Provider?

Based on the above, have you been de-registered or terminated?
(please state if the outcome (decision) is pending and the expected due date

Adverse findings

Are there any adverse findings for you as the Named Service Provider?
(please state if the outcome (decision) is pending and the expected due date)

Declaration

Confirmation

I meet my professional association requirements for current membership (if applicable), and I comply with its codes and procedures, and I have not, in the last five years:

  • had my employment or affiliation terminated for disciplinary reasons.
  • been detained in a penal institution.
  • been disbarred for proven disciplinary reasons from membership of an organisation or body.