Review application




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Fill in this form if you want a decision we’ve made about your claim or your levies to be independently reviewed.

About this form

Before you fill in this form, please read the following information:

You need to apply for your review within three months from the date of our decision letter. If you’re unable to meet this timeline, please get in touch with us so we can talk about it

It’s really important to fill in all the sections of this form, including signing and dating the declaration. We may return the form to you if there is any missing information

If you need any help with this form please contact the person at ACC who has been helping you with your claim or levies. Or contact us on 0800 101 996.

Returning this form

When you’ve finished, please return this form to the address for its review type:

for standard reviews: ACC Review Unit, PO Box 242, Wellington 6140 or accreviewapplication@acc.co.nz

for reviews about levy decisions: ACC Business Service Centre, PO Box 795, Wellington 6140 or Legal-Commercial@acc.co.nz.




1. Your details

Your name:      

Your address:      

Your postal address, if different:      

Your contact phone number:      

Your email address:      




2. Your review details

Please provide the date of our decision letter or the date you received our advice so we can look into your review. It’s also helpful to include any records that support the reasons that you disagree with our decision.

What’s the date of the decision letter or the date you got the advice that you want to be reviewed?

     

Is this review about a decision made on your own personal claim?

 Yes

 No

If yes, what is your claim number (you’ll find it on your claim letter)?      

If no, please tick the box that applies to you:

 Representative

 Employer

 Levy review

If you’re submitting a levy decision review request, what’s your ACC number (from your levies letter)?      

If you’re a representative of a person who wants their decision reviewed, you’ll need that person’s authority to act on their behalf.

 I’ve attached a document confirming that the person I’m representing has given me authority to act on their behalf.

What’s the full name of the person who’s given you their authority to represent them?

     

What’s the claim number of the person you’re representing?      

What’s the address of the person you’re representing?      




3. The review reasons

Are you applying for a decision review within three months of the decision date?

 Yes

 No

If no, please explain the reasons you were unable to apply within three months. You can include information that supports your reasons, eg medical certificates. Please note that we cannot extend review time for levy or employer decision reviews.

     



Please explain the reasons you disagree with our decision. Please include any information that supports the reasons you disagree with our decision, eg medical records. You can attach extra pages if you like.

     


What would you like to happen as a result of this review, eg I would like ACC to pay for my knee surgery?      





4. What happens next

After we receive your review application:

we’ll review any new information provided and reassess our original decision. This sometimes results in a new decision

we’ll keep in touch to let you know what’s happening with your review

if we’re unable to work together to resolve the issue, we’ll ask an independent reviewer to review our decision at a review hearing.

If your review application results in a review hearing:


  • it’s a good idea to think about what information you’ll give to support your review hearing

  • an independent reviewer will get in touch to arrange a review hearing with all of the parties who are entitled to be present and heard at the hearing

we’ll send relevant information about your case to anyone with an interest in the review who also has the right to speak at the review hearing

If you decide you don’t want to go ahead with a review hearing, you can withdraw your review application.

If you decide to do this, we’ll need to know in writing. You can either fill in a form (an ACC34 Request to withdraw a review, which you can get from us) or send us a letter.

If you need any help with your review, please get in touch with us on 0800 101 996.






5. Cultural support services available for review hearings

If your review application results in a review hearing, you have the right to:

whānau, kaumātua or family support to be present

interpreters, if required, for you or your support person(s) to translate at your review hearing

have your review hearing at an appropriate community venue, if possible.

Please tick the box below if you’d like more information about the cultural support services we can provide.


 Please contact me about cultural support services if my review application results in a review hearing.




6. Documents for your review – claims/other hearing

Complete this section only if you are requesting a claims or other non-levy issue hearing.

If a claims review hearing is needed, we’ll send you copies of all the documents we think you’ll need to help you prepare. For claims issues only, if you’d like us to courier you the documents, we can send them on a password protected CD or as a printed copy of your documents.

For your privacy, we prefer to send a password protected CD.

Please tick one box for the document format option that you prefer.



 Password protected CD

 Printed documents

For security reasons, we’re unable to send a printed copy of your claims issues documents by normal post.

Please tick only one box below to choose how to receive your documents.



 I’ll contact ACC on 0800 101 996 to talk about how ACC can deliver the printed documents to me

 I’ll collect the printed documents from the following ACC branch location:  






7. Documents for your review – levy hearing

Complete this section only if you are requesting a levy issue hearing.

If a levy issue review hearing is needed, we’ll send you copies of all the documents we think you’ll need to help you prepare for it. For a levy issue review hearing, we can send you a printed copy of your documents by normal post or by courier. We can also email your review documents.

Please tick only one box below to choose how to receive your documents.


 I agree that ACC may courier my review documents to me

 I agree that ACC may post my review documents to me at my postal address

 I agree that ACC can email my review documents to me at my email address.




8. Declaration and signature

I confirm that to the best of my knowledge:

I am authorised to apply for this review



the information I’ve provided on this form is true and correct.

Signature:

Date:     

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy Code 1994. 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.

ACC33 February 2016 Page of 4


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