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Consent ACC 167 form

#1 Guest_NoRehab_*

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Posted 19 December 2003 - 10:02 PM

Here is a copy of 2 other vrsions of the ACC 167 form:

Posted Image


and this one too

http://www.accforum....-1099965300.jpg

:twisted:


Next time you get an arc18, cross out the section on collection of info at
the bottom and initial it, then send it together with the form supplementary sheet

Supplementary Sheet

Collection of info is covered by sec 72 1 ( c ) but
their acc 167 is a blanket authority which in our view contravenes the
privacy act principles.

Send both with a covering letter stating that consent is given subject to
the conditions contained in the enclosed supplementary sheet Supplementary Sheet it is to be attached to
and read in conjunction with the acc 167 form and is valid for the duration
of the current arc 18 medical certificate
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#2 Guest_NoRehab_*

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Posted 19 December 2003 - 10:03 PM

Responsibilities of claimant who receives entitlement

Responsibilities of claimant

72 Responsibilities of claimant who receives entitlement

(1) A claimant who receives any entitlement must, when reasonably required
to do so by the Corporation,---

(a) give the Corporation a certificate by a registered health
professional or treatment provider that deals with the matters and contains the
information that the Corporation requires:

(B) give the Corporation any other relevant information that the
Corporation requires:

© authorise the Corporation to obtain medical and other records that
are or may be relevant to the claim:

(d) undergo assessment by a registered health professional specified by
the Corporation, at the Corporation's expense:

(e) undergo assessment, at the Corporation's expense:

(f) co-operate with the Corporation in the development and
implementation of an individual rehabilitation plan:

(g) undergo assessment of present and likely capabilities for the
purposes of rehabilitation, at the Corporation's expense:

(h) participate in rehabilitation.

(2) Every such claimant must give the Corporation a statement in writing
about any matters relating to the claimant's entitlement, or continuing
entitlement, to an entitlement that the Corporation specifies, and must do so
whenever the Corporation requires such a statement.

(3) If the Corporation requires the claimant to do so, the claimant must
make the statement referred to in subsection (2) as a statutory declaration or
in a form supplied by the Corporation.
Compare: 1998 No 114 s 115
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#3 Guest_NoRehab_*

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  Posted 19 December 2003 - 10:25 PM

Here is a copy of the Supplementary Sheet - use it in conjunction with consent forms

Supplementary Sheet for the consent to collect/release information



SUPPLEMENTARY SHEET ATTACHED TO BE READ INCONJUNCTION WITH THE CLAIMANT CONSENT FOR THE RELEASE AND COLLECTION OF INFORMATION

(To also be read in conjunction with any medical certificates or similar documents issued during the period of the Claimant Consent for the Collection and Release of Information remains in effect)

Collection of Information:
* No information is to be collected from any person or organisation unless first
authorised by me (Privacy Principle 2 (2) (a) to ensure that such information is
collected for a lawful purpose and that it is necessary for that purpose (Privacy
Principle 1(a) and (. This will ensure that I am aware at all times of what
information is being collected and the reasons for same.

* No report, opinion, assessment or similar material is to be obtained from any
medical professional/practitioner or any other person or organisation without my
informed consent and, if necessary in my view, the opportunity to be present for
examination and to contribute material to any such report, opinion, assessment
or similar material as I think fit (Privacy Principles 1, 2, 3,4, 5, 6, 7, 8, 9 and 10).

This will avoid, for example, the commission of any medical report without my being personally examined and/or being afforded the opportunity to ensure that any third party such as a medical practitioner has all the relevant and correct information.

* All telephone calls about me are to be noted in writing with the time, date parties
and a summary of the conversation and its purpose(s). All ‘E’ mail generated by
you or received by you is to be converted to hardcopy.

* Copies of all information generated as above are to be supplied to me regularly or
upon request (Privacy Principles 3 (1) (g), 6 and 7).

Release of Information:

* No information whatsoever is to be released about me to any person or
organisation unless first cleared by me to ensure the accuracy of any such
information it is proposed to release (Privacy Principles 7, 8, 10 and 11) and to
ensure that I have the opportunity to correct any such information it is proposed
to release to hardcopy.

* Copies of all information generated as above are to be supplied to me regularly or
upon request (Privacy Principles 3 (1) (g), 6 and 7).

* ACC acknowledges that it is an agency within the meaning of sections 2 (1) and 3
(4)of the Privacy Act 1993 and is bound by the provisions of the said Act including
section 88 whereby damages shall be payable for any breach of the Claimants
privacy including the requirements set out above.

Claimants Signature

Date

ACC Case Manager

SIGNATURE

DATE

Attached File(s)


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#4 User is offline   Bellbird3 

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Posted 19 December 2003 - 11:53 PM

In my experience the latest is that I was asked by my CM to provide a consent form ( not a standard form ) for the release of information to the service providers
( entitlement assessors in this case)
I have been told from a support group source that ACC are now requesting consent forms on a 'case by case' basis.
This means that you are now able to write your consent form / letter in your own words and construct the consent form / letter to be appropriately worded to suit the issue or assessment at hand.
This has to be an improvement surely ?
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#5 User is offline   doppelganger 

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Posted 20 December 2003 - 05:46 PM

when writing any concent form "That any invormation released is not to be used for any criminal convictions" should be added. the ACC can get information for criminal investigation with out any one releasing information from the ACC.
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#6 Guest_NoRehab_*

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Posted 29 December 2003 - 01:22 PM

URGENT

There are some disturbing changes made to the Claimant authority for the collection of information forms being sent to claimants to sign. Legal advice suggests this form may well be in breach of ACC's Code of Claimants' Rights, Right 7. You have a right to have privacy respected.

1. FIRST PARAGRAPH

While the heading on the form is for COLLECTION, the first sentence make it clear it is a consent for BOTH COLLECTION and RELEASE, not just collection.

In the first paragraph all claimants should insert after "about me" the words "that is directly pertinent to my accident claims and subject to the attached amendments." This should be initialled.

2. SECOND PARAGRAPH

The Corporation has added a disturbing clause at the end of this paragraph which differs from previous forms. Previously it stated:

I understand this authority relates to all aspects of my claim, including ANY external agencies or service providers (such as GPs, specialists, assessment agencies and employers). ACC have now added the words:
"and empowers any such organisation to provide to provide the information requested directly to ACC."

This would therefore over-ride the requirements of the Privacy Act and the Health Information Privacy Code as relates to the conduct of ANY SUCH AGENCIES. This can not be allowed. Suggest "and empowers any such organisation to provide to provide the information requested directly to ACC" must be crossed out and replaced with the following amendment:

"providing that I am notified and my prior consent is obtained on each separate contact."

3. THIRD PARAGRAPH

In this paragraph it now states:

"I understand that this authority is valid for the period ACC provides assistance on this claim, unless I negotiate a different arrangement with my case manager."

This is in direct conflict with the statements made by ACC case managers that:

CURRENT Corporation POLICY is that the claimant consent authority for the collection and release of information must be renewed every twelve months.

While it may be that some claimants negotiate 3 month or 6 month renewals, the current wording on this form allowing an endless time "for the period ACC provides assistance on this claim" is in conflict with the Corporation's own policy.

This should be crossed out and replaced with:

"period of one year. ACC has confirmed their own policy requires renewal every 12 months."
(or if 3 months/ 6 months are preferred make the period 3 or 6 months as required).

4. Claimant's declaration.

At the end of the first sentence add:

"subject to the attached amendments."

If the Supplementary Sheet used by many claimants is attached add:

"subject to the attached amendments and in conjunction with the requirements of the attached supplementary sheet."

ADD at the bottom of the form:
"To be read in conjunction with the attached supplementary sheet at all times."


N.B.
Initial all the amendments you have made on the form.
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#7 User is offline   fairgo 

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Posted 19 January 2004 - 09:04 PM

I would be very interested to know which branches are asking for consent on a case by case basis. This is a new one on me... previously it has had to be requested (no make that demanded) by the claimant 9and usually through a lawyer) before the branch will comply.
Info on this greatly appreciated. Privately if you wish to
[email protected]
:ph34r:
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#8 Guest_ACC's Nightmare_*

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Posted 13 March 2004 - 11:10 AM

ACC SAY THIS ABOUT CONSENT AND SUPPLEMENTARY FORMS

four pagesss

Attached File(s)


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#9 Guest_ACC's Nightmare_*

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Posted 13 March 2004 - 11:11 AM

second page

Attached File(s)


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#10 Guest_ACC's Nightmare_*

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Posted 13 March 2004 - 11:13 AM

third page

Attached File(s)


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#11 Guest_ACC's Nightmare_*

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Posted 13 March 2004 - 11:14 AM

page 4

Attached File(s)


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#12 User is offline   fairgo 

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Posted 13 March 2004 - 05:40 PM

absolutely brilliant!!! we now know that ACC have accepted the fact that we are ENTITLED to give consent on a case by case basis AND informed consent.... wahoooooooooooooooooo :D
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#13 User is offline   Kiwee 

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Posted 13 March 2004 - 09:48 PM

So acc are saying they dont take the piss afterall. And i can certainly vouch they won't let you take the piss either. On friday I turned up toa medical appointment at ACC /Workwise Tower in Wellington after a 1.5 hour drive to be there very early in the morning. On arriving at reception and asking if my support person or I could please use the "rest rooms" we were told it was ACC policy not to allow the use of these rooms by members of the public (or stock). We were directed downstairs and acrosds the road to the local service station, not a fun walk in the early morning mad wellington traffic. The medical appointment was held in a room set up for medical examinations, yet they expect you to prepare for that across the road at the local gas station? Fair go ACC, if you came to my place I wouldnt send you out on the street, its a big building surely restrooms are available...especially for medical examinations. What if i had been in a wheelchair or had to change in private because of a colostomy bag or something. Miserable buggers.
It hardly fits the ACC Claimants Code of Rights as far as being treated with dignity is concerned
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#14 User is offline   sidcoon 

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Posted 14 March 2004 - 12:47 AM

am lucky in sum ways if i need to go i have to no holding on ( i would of let rip write there on the floor ) lets face it we own the place we pay for it. :rolleyes: christ this nice country is be coming a sad place to live ,the govement need to get there head out of its ass wipe the shit of there faces and have a dam good look at what they are doing to the place and the poeple :angry:
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#15 User is offline   BillyBob 

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Posted 14 March 2004 - 08:35 AM

Too right, you should have just pissed in a pot plant in the reception.

This would be well worth a complaint against the code of rights.
At the best you would get an appology but it may make them do something to make it easier for the next person who wants to use the toilets.

Its inhumane treatment and would have been interesting to have refused to undergo the assessment owing to substandard conditions provided for this.
or
You could have gone directly to Dysons office and asked to use hers.

cheers
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#16 User is offline   jocko 

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Posted 14 March 2004 - 09:01 AM

You can not use Ruths. She is on it all the time these days. So is Helen so is Cullen. or should I say Cull'em. Yuk! did you see the bloke on tv sucking bull semen through a straw at the wild foods thingy??? I hear when cullen wants to make a statement he does the same thing in preperation. Except he sticks the straw up the bulls arse and sucks!!!!!!!!!!!!!!!!!!!!!!!!! yahoo! cheers jocko
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#17 User is offline   roamy 

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Posted 18 March 2004 - 02:33 AM

acc's nightmare,you little ripper, i don't know how you get this internal acc stuff, but keep up the great work.Got anymore gems like this.roamy
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#18 Guest_IDB_*

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Posted 18 June 2004 - 10:05 PM

Acc have acknlowledged that claimants have the legal right for informed consent on a case by case basis for the collection and release of information, for example,

If the ACC wish to refer a claimant for an assessment acc must seeky our appoval to release your details to that said assessor and they must clearly lit all reports and information they wish to release to that person,( be aware you do not sign that release unless they list all the relevant reports and information to be sent).

ACC have said they have the requirement of claimants to respond within a reasonable period of time when ACC seek your approval for the collection and/or release of informaton

A senior team leader recently admitted this at mediation. The case manager was over ridden by the team leader on this occasion (CM wanted acc167 signed unedited, remember to cross out all the information you disagree with, preferably with a black felt pen.)

so there you have it, USE the Supplementary sheets ( in the form Letters Slot) attached to ANY consent form, especially the ACC167 form.

Click Here for the
Supplementary Sheets

Here is a sample form. Below it is some advice on altering it for your best interest.

Posted Image

Here's some advice kindly passed on in regard to the ACC 167 form

There are some disturbing changes made to the Claimant authority for the collection of information forms being sent to claimants to sign

Legal advice suggests this form may well be in breach of ACC's Code of Claimants' Rights, Right 7. You have a right to have privacy respected.
  • FIRST PARAGRAPH

    While the heading on the form is for COLLECTION, the first sentence make it clear it is a consent for BOTH COLLECTION and RELEASE, not just collection.

    In the first paragraph all claimants should insert after "about me" the words "that is directly pertinent to my accident claims and subject to the attached amendments." This should be initialled.

  • SECOND PARAGRAPH

    The Corporation has added a disturbing clause at the end of this paragraph which differs from previous forms. Previously it stated:

    I understand this authority relates to all aspects of my claim, including ANY external agencies or service providers (such as GPs, specialists, assessment agencies and employers). ACC have now added the words:
    "and empowers any such organisation to provide to provide the information requested directly to ACC."

    This would therefore over-ride the requirements of the Privacy Act and the Health Information Privacy Code as relates to the conduct of ANY SUCH AGENCIES. This can not be allowed. Suggest "and empowers any such organisation to provide to provide the information requested directly to ACC" must be crossed out and replaced with the following amendment:

    "providing that I am notified and my prior consent is obtained on each separate contact."

  • THIRD PARAGRAPH

    In this paragraph it now states:

    "I understand that this authority is valid for the period ACC provides assistance on this claim, unless I negotiate a different arrangement with my case manager."

    This is in direct conflict with the statements made by ACC case managers that:

    CURRENT Corporation POLICY is that the claimant consent authority for the collection and release of information must be renewed every twelve months.

    While it may be that some claimants negotiate 3 month or 6 month renewals, the current wording on this form allowing an endless time "for the period ACC provides assistance on this claim" is in conflict with the Corporation's own policy.

    This should be crossed out and replaced with:

    "period of one year. ACC has confirmed their own policy requires renewal every 12 months."
    (or if 3 months/ 6 months are preferred make the period 3 or 6 months as required).

  • Claimant's declaration.

    At the end of the first sentence add:

    "subject to the attached amendments."

    If the Supplementary Sheet used by many claimants is attached add:

    "subject to the attached amendments and in conjunction with the requirements of the attached supplementary sheet."
ADD at the bottom of the form:
"To be read in conjunction with the attached supplementary sheet at all times."


N.B.
Initial all the amendments you have made on the form


and lastly, ACC have acknowledged your rights, this from ACC itself.

http://www.accforum....-1079133046.jpg

http://www.accforum....-1079133114.jpg

http://www.accforum....-1079134122.jpg

http://www.accforum....-1079133269.jpg
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#19 User is offline   flowers 

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Posted 19 June 2004 - 07:22 AM

Well does that mean that ACC can do what they like and if we refuse to sign they will start non compliance process?
Do they have these powers under the act's?
It seems we not only lost 20% of our income we lost all our rights as well.
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#20 User is offline   freefallnz 

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Posted 25 September 2005 - 10:43 AM

Bizzare Twists?

Well having just recieved another Photocopy of an ACC 167 form for my signature, I jumped into the forum to print off a copy of this Supplemental sheet.

I did think it was strange that the ACC 167 form I had been supplied contained the following term "I understand that this authority is valid for the period ACC provides assisstance on this claim, unless I negotiate a different arrangement with my case manager."

My understanding was that the Privacy Commisioner some years ago had instructed ACC that requesting open ended consents was not legal and that all consents had to have an expiry date. And as can seen on this thread ACC's then adopted the Policy too limit consents to a year.

Anyways heres another version of the ACC 167 form.

Posted Image

Note the uneven spacing between the paragraphs marked * No printer or printing company on this earth would allow such a badly typeset document to be printed !!

So of course my questions are..

Why did my CM provide me with a Photocopy/printed version of the form and not an original consent printed in genuine ACC colours ?

Can the North Harbour Office not afford to maintain stocks of genuine stationary ?

or

Is there such a thing as a standard ACC 167 form ? do case managers create their own ?
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