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Consent Form New improved version

#41 User is offline   doppelganger 

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Posted 29 November 2005 - 09:33 AM

this is a review application that has been done for some one else .
Use it but make sure that any necessary changes is undertaken.

Review Unit
Review Administrator
Accident Compensation Corporation
Corporate Office
Shamrock House
81-83 Molesworth Street
P. O. Box 242
Wellington
New Zealand

Claim Numbers

Dear Administrator
I am applying for a application to review the corporation reason to delay my entitlements. The delay to supply of documents held by the corporation for the purpose of supplying the Compensation, rehabilitation, treatment and other entitlements.
The corporation has had request for a consent form to be signed but has failed to inform me in what entitlements that the corporation is going to supply

Section 134 (1) A Claimant may apply to the Corporation for a review of ---
(b) any delay in processing the claim for entitlement that the claimant believes is an unreasonable delay.

The entitlements that is being looked are Compensation, Treatment, and both Social and Vocational Rehabilitation.
The Corporation has repetitively requested that forms for the release and collection of information are to be signed and returned. As there must be a purpose for these forms to be requested in line with Act mainly section 3 and section 200 Crown Entities Act 2004 (2004 No 115)
It is found that a request to supply or release of information with out any entitlements being supplied or looked at being supplied is with holding some entitlements.

The Consent form dated __________ revoked all previous forms and expresses that the claimant must be notified of the information and the purpose of the information to be collected or / and released.

Jurisdiction; as this is a review due to the case manager not supplying the information about the entitlements that the information is going to be used for, it is in the claimants view that the claim manager is delaying the processing of the claim for entitlements even if there is no entitlements allowed under the Act.


Yours
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#42 User is offline   Huggy 

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Posted 03 December 2005 - 01:22 PM

Well folks today i got another letter from my cm. The new Consent for the collection and release of Information which i got from acclaim has yet again been turned down. Same letter as last time when the consent form from the forum was sent to them however there is a slight change in the first paragraph.

ACC has received your letter dated 24th November requesting that an amendment be attached to the ACC consent form. The indication to me of ACC policy is now clear and unfortunately we are unable to accept the form you sent us. ACC does note that you have in any case apparently withdrawn consent provided.


So now they are saying they have accepted that all previous consents are revoked however they will not accept any of the others i have sent in.
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#43 User is offline   chelle's 

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Posted 16 December 2006 - 09:42 AM

You've got to admire acc's sense of self, really. An organisation that believes it is above the law.......heil hitler!!

The issue of privacy and acc's interpretation is going to continue to be used and abused for as long as they can use it to deny/delay claimants their legal entitlements.

I had an issue with my cm forwarding an email to the dr who carried out an assessment. Her reason for sending it was because I disagreed with the drs diagnosis.

This was the reply I received from the acc complaints dept....

"As for your questions being passed onto Dr XXXXX, Jamie has explained to me that the consent form you signed allows them to disclose information to agencies that carry out assessments on our behalf, treatment providers or employers, that help us to assess your individual needs for treatment and rehabilitation services.
ACC does not require a specific authority to disclose information to a provider or assessor, providing the information is being used for the purpose for which it was originally gathered, that is, the management of your claim."


When I sent my complaint through I attached the privacy disclaimer they have on the bottom of their emails. Unsurprisingly enough, according to acc it only covers their emails and you can't expect the same sort of courtesy regarding your own communications.
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#44 User is offline   Alan Thomas 

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Posted 26 October 2007 - 06:56 PM

Bump
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#45 User is offline   jaffa 

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Posted 14 April 2014 - 11:26 PM

Paradigm Shift said:

1122979136[/url]' post='18864']
Please have a read of the attached consent form document and suggest modifications if necessary.
Claimant conditional consent #6


Refused by ACC.
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#46 User is offline   Tomcat 

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Posted 15 April 2014 - 08:54 AM

https://nz.news.yaho...of-acc-scandal/


ACC privacy fallout hits thousands
NZ Newswire Updated April 15, 2014, 8:04 am ACC is rushing to change a privacy waiver form after a judge said it was questionable, but isn't committing to destroying all in the information the form allowed it access to.

A District Court judge has ruled ACC illegally withheld payments to claimants who wouldn't sign its "form 167" because the form was too broad in giving ACC permission for information about claimants to be collected, used and disclosed.

ACC's claims management manager Sid Miller admitted the corporation was declining entitlement based on the form.

ACC was changing consent forms, which would be ready in about two weeks, he told Radio New Zealand.

He refused to say whether the all information that had been gathered would be destroyed.

Instead, ACC would be checking with clients to see if they were comfortable with what they had signed away on the old form, or if they wanted to sign the new form.

Staff were now looking through 14 years of client records. About 3 per cent of claims a year signed the form 167 - or 50,000 a year.

"It is a big situation," he admitted. "And we have to address that."

Opposition parties are demanding to know how many people have been refused claims based on the form's privacy waiver.

Labour's ACC spokesman Iain Lees-Galloway says ACC Minister Judith Collins must front up and say how many claimants were refused cover.

"Anyone who refused to fill in the form on the grounds that it gave ACC excessive powers to collect their private information could have been denied treatment and compensation," he said.

However, Ms Collins says the matter is an operational one and she isn't commenting.

The problem with the form was revealed during an inquiry into ACC's huge privacy scandal in 2012 when 6700 private files were sent to claimant Bronwyn Pullar, but nothing was done about it at the time.
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#47 User is offline   hukildaspida 

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Posted 17 April 2014 - 12:56 PM

This was the ACC167 Consent form version that was posted online on http://www.accforum.org in August 2005, there is also an earlier version that should be on here somewhere

Claimant Conditional Consent #6

Claimant terms to authorise the collection and disclosure of information

“Claimants complete this form to provide the Corporation assurances that consent to collect and disclose information will be granted for particularised information as and when required by the Act.”
Claimant details

Claimant's name
Address
Phone number
Home address if different from above

Date of birth Claim number

ACC contact details Return this form to the address below
Your ACC Case Manager is:


ACC office


Phone number
Claimant's delegated consent for the collection and disclosure of information
The claimant acknowledges the need for the Corporation receive accurate information to the claimant's file so as to administer claims and entitlements properly in accordance with S72 ACC Act 2001.

Whenever the Corporation makes reasonable requests for information requests will be particularised in writing so as to preserve an accurate record of what information is required, for what reason and in accordance with what particular portions of the Act. The claimant agrees to make the particular information available promptly once satisfied that the information request is proper and that the information assembled is correct, so as to preserve the integrity of the file ensuring a cost-effective delivery of entitlements.

The Corporation is assured that Core Information requests such as Initial Occupational Assessment, Initial Medical Assessment, Vocational Independence Assessment, any other reasonable medical assessments will be verified so as to meet legislated standards and criteria prior to consent of delivery to the file from such third party assessors. As the Medical Council no longer supervise third party Medical Reports all such reports will be independently considered by the relevant medical treatment providers so as to preserve treatment protocols and funding entitlements that maintain the continuity of treatment integrity supervised by the Medical Council oversight for reasons of safety. The Corporation are expressly forbidden from making any inquiries seeking private information from any third parties, such as employers, colleagues, family, friends or members of the public, that have not been granted express written permission to release such information to either the Corporation, third party assessors or any Corporation information gathering and supplying agent, to the extent that the burden of liability under the Privacy Act is to be shifted, from the person disclosing information to the Corporation requesting information. This form is designed to preclude inaccurate information coming into the possession of the Corporation that could cause any assumption that entitlements may be reduced.

The information needed to be collected will be under the authority of separate written consents, will only be used in relation to the purposes of determining entitlements under the Injury Prevention, Rehabilitation, and Compensation Act 2001. In the collection, use, disclosure and storage of information, the Corporation will at all times comply with the obligations and liabilities of the Privacy Act 1993, the Health Information Privacy Code 1994, Human Rights Act, New Zealand Bill of Rights Act, Summary Proceedings Act and cases of an employee or agent of the Corporation knowingly recurring information that may mislead the judiciary, the Crimes Act.

The claimant and/or representative will have free access to correct any information the Corporation holds about who agrees to allocate case management time as an overriding priority to correct such information found to be wrong. On occasions where the Corporation has failed to address disputed information or correct information known to be wrong, either reported to the Corporation or on the file, all previous consents will be rendered a nullity until the Corporation complies with the requirements to properly address disputed information and to correct wrong information during which time the Corporation will not diminish any entitlement. The Corporation accepts liability for all associated pecuniary losses. By accepting this pro forma consent the Corporation may not suspend any entitlement without making a particular request for particular information it does relate to the claim and the Act.

Provided the claimant’s identity is not disclosed, the claimant authorises unfettered disclosure of information to assist evaluation of services and performance of the ACC scheme and research in relation to injury prevention and effective rehabilitation.
Claimant's declaration
This delegated pro forma consent is made so as to assure the Corporation that only relevant and correct information transference occurs in a timely fashion to the extent that the claimant agrees in advance to provide such necessary consent as and when needed the information so as to allow the Corporation to administer the claim properly and correctly.
Claimant's signature Date ...... /..... /......
Claimant's representative's declaration (If appropriate)

Representative's name
What is your relationship to the claimant?
Why is the claimant unable to sign this form?
I declare that, to the best of my knowledge, I have the authority to consent to the collection and release of information on behalf of the claimant.
Claimant's representative's signature Date ...... /..... /.....
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#48 User is offline   hukildaspida 

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Posted 17 April 2014 - 01:04 PM

As a comparison, this is an ACC167 Consent form version from June 2013

[DOC]
ACC167 Authority for the collection and disclosure of ...
www.acc.co.nz/PRD_EXT_CSMP/groups/.../form/prd_ctrb103999.doc‎
Authority for the collection and disclosure of information. Please complete this form to give ACC your consent to collect and disclose information about you.

Authority for the collection and disclosure of information
Please complete this form to give ACC your consent to collect and disclose information about you.
CLIENT DETAILS This form was completed on: [dd month yyyy]

Client’s full name:

Date of birth:
Claim number:

Address:


ACC DETAILS
Claims Management staff member:
ACC office:


CLIENT DECLARATION
I give my consent for information about me to be collected, used and disclosed to:
• assess my entitlement to compensation, rehabilitation and medical treatment
• help with the evaluation of ACC’s services and performance
• help with research into injury prevention and effective rehabilitation.
I understand that:
• this consent applies to all aspects of my claim and includes external agencies and service providers, such as general practitioners, specialists and employers from whom ACC asks for information
• I have the right to see and correct any information ACC holds about me
• this consent applies for the whole period during which ACC provides assistance for my claim, unless I negotiate a different arrangement with my ACC Claims Management staff member
• the information collected will only be used or disclosed in relation to the purposes of the Accident Compensation Act 2001
• when collecting, using and storing information ACC will at all times comply with the Privacy Act 1993 and the Health Information Privacy Code 1994.
For more information about your privacy rights please refer to the information sheet Collection and disclosure of information.
Signed: Date:


CLIENT’S REPRESENTATIVE’S DECLARATION
I declare that I have authority to consent to the collection and disclosure of information on behalf of the client, and I provide this consent.
Signed: Date:

Representative’s name:
Phone number:

What is your relationship to the client?
Why is the client unable to sign this form?
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#49 User is offline   not their victim 

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Posted 23 April 2014 - 03:43 PM

acc 18 and 45 are about your injury and work status

the 167, is about 3rd party involvement...

acc have no right, to send any info to 3rd parties, without explicit consent...

If all of lay a complaint, and send said complaint to the ACC Board....this will cause complete chaos...

go for it...
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#50 User is offline   Aurora 

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Posted 23 April 2014 - 08:20 PM

View Postnot their victim, on 23 April 2014 - 03:43 PM, said:

acc 18 and 45 are about your injury and work status

the 167, is about 3rd party involvement...

acc have no right, to send any info to 3rd parties, without explicit consent...

If all of lay a complaint, and send said complaint to the ACC Board....this will cause complete chaos...

go for it...


The Board send it all back and say it is an OCI matter and we know how impartial and independent the OCI is. Didn't bother with this route as a waste of time - giving the Privacy Commissioner another go and the HRC - in the light of recent publicity they may find against our dearly beloved acc. Maybe ......
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#51 User is offline   not their victim 

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Posted 24 April 2014 - 12:01 PM

Privacy Commissioner denied the Party Status Files Aurora....


so why would they even begin to take MY SIDE, when quite clearly they too are lying....

Auditor general....and Solicitor General plus the ACC Board....(black ops Ku Seymour)....need to be held accountable for letting this rogue corporation get away with Human Rights Abuse....

Litigation was never meant to be part of the process...

party status means that all inquiries went up the chain of command to acc legal, whereby without your knowledge, an Insurance Adjuster, made sure that your claim was manipulated, before instructions sent back down the chain of command so that the case managers sound intelligent....hahahahaha

However, being litigated against without your knowledge is BIAS...and that too is illegal...
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#52 User is offline   hukildaspida 

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Posted 24 April 2014 - 01:59 PM

3rd Degree ‏@3rdDegreeTV3

Have you ever signed this form? #ACC167 Melanie Reid reveals how ACC has been using your private info - 8.30pm TV3 pic.twitter.com/wVFO0X5Bcs


https://twitter.com/...8167808/photo/1
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#53 User is offline   MINI 

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Posted 24 April 2014 - 03:31 PM

View Postnot their victim, on 24 April 2014 - 12:01 PM, said:

Privacy Commissioner denied the Party Status Files Aurora....


so why would they even begin to take MY SIDE, when quite clearly they too are lying....

Auditor general....and Solicitor General plus the ACC Board....(black ops Ku Seymour)....need to be held accountable for letting this rogue corporation get away with Human Rights Abuse....

Litigation was never meant to be part of the process...

party status means that all inquiries went up the chain of command to acc legal, whereby without your knowledge, an Insurance Adjuster, made sure that your claim was manipulated, before instructions sent back down the chain of command so that the case managers sound intelligent....hahahahaha

However, being litigated against without your knowledge is BIAS...and that too is illegal...


Hi All

My very serious point here, is why get my consent to have my information if ACC Legal have no intention of putting the up to date information in front of the Judge???

If you read Warren's pages 10-27 of Otago's United Nations application, you will find how that affects all of us, when the wrong documentation gets put in front of the Judge at D/C level.

We have no come-back on a wrong decision being made through this type of error, we only have come back on 'question of law', otherwise it is is 'stuck in a rut' and we 'out of pocket'.

Now this is not called fair or Justice in my eyes.

Mini
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#54 User is offline   Aurora 

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Posted 24 April 2014 - 04:49 PM

View Postnot their victim, on 24 April 2014 - 12:01 PM, said:

Auditor general....and Solicitor General plus the ACC Board....(black ops Ku Seymour)....need to be held accountable for letting this rogue corporation get away with Human Rights Abuse....



Hello XXXXXX,

I am no longer the board and corporate secretary. I have passed your correspondence onto the ACC board and corporate secretary, and you should expect a response from him in due course.

Regards

Kurutia Seymour

Sent from my iPad
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#55 User is offline   Aurora 

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Posted 24 April 2014 - 05:01 PM

View PostMINI, on 24 April 2014 - 03:31 PM, said:

Hi All

My very serious point here, is why get my consent to have my information if ACC Legal have no intention of putting the up to date information in front of the Judge???

If you read Warren's pages 10-27 of Otago's United Nations application, you will find how that affects all of us, when the wrong documentation gets put in front of the Judge at D/C level.

We have no come-back on a wrong decision being made through this type of error, we only have come back on 'question of law', otherwise it is is 'stuck in a rut' and we 'out of pocket'.

Now this is not called fair or Justice in my eyes.

Mini


Mini I agree this is serious - I fail to understand why D/C Judges fail to follow standard practice. I have emailed the D/C today to categorically state that submissions from all parties have to be in on time and I will 'foot stomp' to use my lawyers term if ACC legals fail to follow court process and procedure.

Thanks to your sharing of your experience - others are alerted - and we can then make the call. The ACC167 in my claim was used for multiple wrongs and I am going back to the Privacy Commissioner even though I have been denied in the past by them of any breaches -due to this now being a media issue.

I take note of your court experiences and are appreciate your sharing of them. Agreed the ACC167 is made a mockery of when up to date information is denied at D/C level - further corporation illegal practices and one day we will do some damage! I do not mean that as a violent threat - I mean we will get ACC tactics to be further exposed - I am hopeful of some later this year in a different area to you ......
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