ACC111 Register as an ACC vendor

Organisation details

Name of the organisation you want to register as a vendor:

Legal name of your organisation (if different):

What is the primary service you provide? (eg acupuncture, physiotherapy, occupational therapy)

Key ACC contact you have been working with (if known):

Business information

Are you a registered company?

Yes

No

Are you GST registered?

Yes

No

Enter your IRD number:

Address information

Please do not provide a private or confidential address as it may be visible on client records.

Postal Line 1

Postal Line 2

Postal Line 3

Suburb

Region

City

Postcode

Additional address information (optional)

Postal Line 1

Postal Line 2

Postal Line 3

Suburb

Region

City

Postcode

Organisation contact details

Name of the main organisational contact:

What is their job title?

What is their work phone number?

What is their mobile number?

What is their email? An account will only be made active once an email address has been verified.

Is the referrals (purchasing) contact different from the main organisational contact?

Yes

No

Is the payments (remittance) contact different from the main organisational contact?

Yes

No

Access to digital services

What digital services do you want to register for?

My vendor organisation uses a practice management system, and I’ll need to apply for a digital certificate to submit ACC forms.

I need access to ProviderHub to enable me to submit ACC45 injury claims forms and/or ACC40 invoices and perform online queries.

None of the above, I intend to deal with ACC via post.

If you use or plan to use a practice management system or accounting software, tell us the name of the system you use / will use:

Payment information

We need a copy or screenshot of the bank account details for the account you want us to make payment into. Please ensure that your bank account name, number and bank logo are clearly visible.

Please email this to:

Email: registrations@acc.co.nz

Do you have authorised signatories who can approve change requests on behalf of your organisation?

Yes, I can supply the details of the authorised signatories

No, I am a sole trader or provider

Conditions for doing business electronically with ACC

All forms transmitted electronically to ACC must be true and correct, and submitted in line with the specifications and protocols notified by ACC from time to time.
Invoices must only be submitted for services provided to a client, in accordance with the provisions of the applicable ACC legislation or contract.
ACC may cancel its permission for you to submit forms electronically at any time without liability for any costs or compensation by giving two weeks’ written notice.
Adequate procedures must be put in place to ensure the ACC system security standards, as set out in ‘ACC Security Policy for Electronic Business’, are met.

Declaration

Your name:

Your job title:

I confirm the information given in this application is true and correct and I am authorised to make this declaration on behalf of the organisation.

ACC111 Register as an ACC vendor

What you need to fill out this form

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