ACC6423 Completion report - ACC - Home



Complete this form if you’re a provider and a client has completed their treatment under the Integrated Services for Sensitive Claims (ISSC).

Please return the completed form to: sensitiveclaimsproviderreports@acc.co.nz

|1. Client details |

|Client name:       |Claim number:       |

|Date of birth:       |Address:       |

| Adult | Child or young person |

| Female | Male | Non-binary |

| | |Preferred pronouns and/or other information |

| | |      |

|Ethnicity:       |

|Contact details / Safe contact where appropriate:      |

|Oranga Tamariki status, if applicable:       |

|Client’s covered injuries (if applicable):       |

|Please complete the following if the client is a child or young person. |

|Guardian/s name/s:       |

|Relationship to client:       |Guardian/s phone number(s):       |

|Guardian address/es, if applicable:       |

|What is the legal status of the guardian/s in relation to the client?       |

|Are there any reasons why ACC should not contact the legal guardian/s?       |

|Oranga Tamariki status, if applicable:       |

|2. Supplier and provider details |

|Supplier name:       |Supplier ID:       |

|Lead provider name:       |Lead provider ID:       |

|3. Client’s current situation |

|Please briefly describe the client’s situation at the end of their treatment. |

|Please describe the client’s presentation. This can include comments on the client’s medication and overall health, as well as their current |

|emotional, behavioural and social functioning: |

|      |

|Please describe the client’s living situation. This can include the client’s current family or whānau situation, their work or school life, their |

|financial position, any current stresses associated with their situation, and the support and expectations of others: |

|      |

|Please describe any current risk factors for this client. Please consider all areas of vulnerability including areas where the client may be at |

|risk to themselves, to others or from others, and including lifestyle and mental health factors: |

|      |

|If there is an ongoing risk of harm to self or others, or risk from others has been identified, please explain how these will be managed post |

|completion of ISSC services: |

|      |

|Please indicate any providers, specialists and agencies that continue to be involved in the client’s recovery and care |

|Name: |Role(s): |Organisation: |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|4. Client’s Personal Wellbeing Index (PWI) |

|Domain |Initial measure |Current measure |

|Date administered: |      |      |

|Life as a whole (optional) |      |      |

|Standard of living |      |      |

|Personal health |      |      |

|Achieving in life |      |      |

|Personal relationships |      |      |

|Personal safety |      |      |

|Community connectedness |      |      |

|Future security |      |      |

|Spirituality and religion (optional) |      |      |

|Personal Wellbeing Index |0.00 |0.00 |

|Fields automatically calculate PWI. Put cursor in field and press F9 to update | | |

|Version of test administered: | Adult | School child | Intellectual disability |

|Additional comments |

|      |

|5. World Health Organisation Disability Assessment Schedule 2.0 |

|Results of the World Health Organisation Disability Schedule 2.0 (WHODAS 2.0). If the client’s rating score was done more than 3 months ago, please|

|complete a new rating. Please do not use this measure if the client is under 18 years of age. |

|Please do not complete this part of the ACC6423 if the WHODAS 2.0 report is for completion of Support to Wellbeing (Short term). |

|Domain |Score |Domain |Score |

|Understanding and communicating: |      |Getting around: |      |

|Self-care: |      |Getting along with people: |      |

|Life activities – household: |      |Life activities – school or work: |      |

|Participation in society: |      |Total disability score: |      |

|Qualitative data:       |

|Provider that completed WHODAS 2.0:       |Date completed:       |

|6. Summary of the client’s treatment progress |

|Please provide a brief summary of the treatment progress the client has made, with reference to Recovery Goals, where applicable: |

|      |

|7. Self-management plan |

|Please briefly describe the self-management plan developed with the client: |

|      |

|Please describe any recommendations for future treatment or check-ins (including Maintaining Wellbeing if required): |

|      |

|8. Other information |

|Please indicate the date of last face to face meeting with the client:       |

|Please provide any other information that you consider relevant. Attach additional pages if required and expand this section as much as you need. |

|      |

|9. Provider declaration |

| I have informed the client/guardian/s that the information collected for this report will be sent to ACC and I have obtained the |

|client’s/guardian/s authority for this. |

|I confirm that the information contained in this report is accurate and that I have followed the standards as set out in the ISSC Operational |

|Guidelines. |

|Signature (provider): |Date:       |

|Provider name:       |Provider ID:       |

When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For further details see ACC’s privacy policy, available at acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001.

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