ACCIDENT INJURY SUPPORT TRUST

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1 ACCIDENT INJURY SUPPORT TRUST TE ROOPU O TE POU O PAKARARA Registration Pack Independent Support for ACC Clients 103 Frimley Avenue, Frimley, Hastings 4120 Phone: Fax: (06)

2 CLIENTS COPY Please keep for your information Dear Client, Included in this pack are our registration forms, authority forms as well as a questionnaire. Please fill out these forms and post them to us as soon as possible to the above address. Once we have received the information back from you we will request your ACC files, please note this can take up to 3 weeks. Once we have your ACC files, we will read them and contact you with the course of action that we will be taking. We will then make a first Appointment, at which we will discuss your claim. We do ask that at this first meeting, you bring any relative documents you may have from ACC including Decision letters. As well as the Registration Fee of $ Our account is ASB :00 Please include your name. We also want to make you aware that as on the membership registration form, it states that you wish to donate 10% of net payments you receive if you have a positive outcome from a review or appeal or other settlement process eg Lump Sum Payment or Back dated Weekly Compensation. All donations are tax deductible. Your support in this way enables us to provide a service to claimants such as yourself at minimum cost, and we would appreciate your willingness to contribute. We understand that this can be a stressful situation and we will get back to you in due course. Thank you. AIST Team Please refrain from cold calling, always ring for an appointment otherwise we cannot process all our claimants cases in a timely manner!

3 REGISTRATION DATE: File No NAME: DATE OF BIRTH: ADDRESS: TELEPHONE NUMBER: ADDRESS: SECOND POINT OF CONTACT PERSON & PHONE NO: ETHNICITY: HOW DID YOU HEAR ABOUT US? I understand that a registration fee of $ is payable on registration. ( Subject to the attached conditions) Costs: Our low cost service is designed for those who can not afford legal fees. Conditions do apply if you wish to enrol with the Accident Injury Support Trust see attached details. If you are represented at Mediation, Review or Appeal hearings, it is agreed that costs incurred and awarded for this representation (Apart from the claimants own expenses) shall be paid direct to the Access Legal Solutions Ltd Bank Account. Claimants will be requested to pay an additional Surcharge for Specialist reports or any GP charges for acquiring information that may be required to support Review and Appeal hearings at which you will be represented by Access Legal Solutions (NZ) Ltd We are a voluntary organization relying on donations to cover costs. If we are successful with obtaining entitlement for you, your donation would be appreciated. Note 1 Note 2 Note 3 Many claimants ask for guidelines relating to donations. See attached guide. All donations are tax deductible. All legal advocacy work relating to Reviews and Appeals will be carried out on your behalf by Access Legal Solutions (NZ) Ltd who will liaise with you at our premises. Advocacy charges for costs incurred on your behalf by Access Legal Solutions (NZ) Ltd will not exceed costs awarded at review or appeal. Entitlements as distinct from costs, are paid direct to claimants by ACC. Disclaimer: Accident Injury Support Trust will endeavour to provide relevant and accurate information to claimants on ACC matters. I understand that Accident Injury Support Trust takes no legal responsibility for matters relating to my claim. I accept the conditions outlined above. Signed: Date:

4 This Questionnaire will be held in confidence on your file; it is designed to help us to efficiently assist you with your claim. QUESTIONNAIRE Q1 Name: Q2 Who is your GP and address? Q3 ACC Claim No If Known: Q4 ACC Case Manager if Known: Q5 What is your injury/injury s that you require our assistance with? Q6 What date did this Injury occur? Q7 Please give a brief description of how you obtained your injury or the circumstances surrounding your injury?

5 Q8 Do you currently receive any assistance from ACC, if so what assistance? Q9 Do you receive any assistance from any other agencies? Q10 Have you seen any medical professionals other than your GP in relation to this injury? (If so please list their names if you can.) Q11 Please briefly describe what you would like us to achieve for you with regards to the outcome of your claim with ACC. Q12 Is there any other additional information you wish to advice us off? Have you already filed For Review or Appeal (if so, Please quote review number and include copies of all

6 correspondence Decision letters etc) PERMISSION TO ASSIST WITH HEALTH CARE PROVIDERS CONSENT TO COLLECT/RELEASE INFORMATION I. give consent for:..john Grove Julayne Barrett Margaret Grove Of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd, legal advocates, to assist me as a Support Person, with all matters relating to my treatment as a patient at the Hawkes Bay Healthcare Hospital and any other Health Care provider within New Zealand. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd Bank Account.

7 Dated: Signed: PERMISSION TO ASSIST WITH ALL ACC & SENSITIVE CLAIMS CONSENT TO COLLECT/RELEASE INFORMATION I. Give consent for:..john Grove Julayne Barrett Margaret Grove of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd (ALS) to assist me as a Support Person and Agent with ALL ACC related matters such as ALL ACC & Sensitive Claim documents including a Claims Schedule and IA/LS history pertaining to ALL of my ACC Claims Note: To comply with ACC guidelines relating to Privacy issues, this authority stays in place till written advice of withdrawal by the client. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd bank account. Dated:

8 Signed: Note: I understand that this CLIENT consent is CONTRIBUTION valid for the period GUIDE that the Accident Injury Support Trust provides assistance and support to me. ACC now require a fresh authority every 6 months. PERMISSION TO ASSIST WITH APPLICATIONS FOR REVIEWS & APPEALS I. Give consent for: John Grove Julayne Barrett Margaret Grove of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd to assist me as a Support Person and Agent with ALL ACC related matters such as APPLICATIONS FOR REVIEWS AND APPEALS pertaining to my case as appropriate. I give consent for a minimum period of 2 years. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd Bank Account. I understand this allows ALS to apply for Reviews or Appeals on my behalf should ALS feel it necessary to do so.

9 I give full consent and accept that the ALS will always act in my best interests. Dated: Signed:

10 APPOINTMENT OF LEGAL ADVOCACY REPRESENTATIVE I.. HEREBY APPOINT Access Legal Solutions (NZ) Ltd to act as my legal representative at any Mediation, Review or Appeal hearings related to my Claim (s) with the Accident Compensation Corporation. It is agreed that costs incurred by me with ALS related to any Mediation, Review or Appeal shall be invoiced to me and recovered from any subsequent award of costs by Reviewers under the Review Costs Regulations of the Accident Compensation Act 2001 or by a Judge in the District Court. I direct that any such costs awarded be direct credited by the Accident Compensation Corporation to Access Legal Services (NZ) Ltd Bank Account I understand that Access Legal Solution (NZ) Ltd and it s staff take no legal responsibility for matters relating to my claim (s). Signed. Date.

11 ACC 5937 Authority to act Use this form to authorise someone to act on your behalf. YOUR DETAILS Client name: [Client full name] This form was completed on: [dd month yyyy] ACC number: [ACC number] Postal address: [Client postal address] Date of birth: [Client DOB] address: Home phone: Mobile phone: Work phone: AUTHORITY TO ACT DETAILS OF THE PERSON YOU ARE GIVING AUTHORITY TO ACT ON YOUR BEHALF. Full name: [Authorised person full name] Date of Birth: [DOB] Relationship to client: Address: [Authorised person postal address] Send all correspondence to this address. Please tick if you would like all correspondence to go to your authorised person. address: Home phone: Mobile phone: Work phone: ACCESS This authority to act covers (tick ONE only): Specific claim(s) only. Please list specific claim number(s): All claims, including future claims. This authority is valid until (tick ONE only): [dd month yyyy] Further notice. DECLARATION I authorise ACC to carry out or initiate transactions in accordance with this authority. I understand that ACC is not liable for any action done in accordance with this authority. I understand that this authority comes into effect from the date ACC receives and processes this form. I understand that I am giving my nominated person authority to access my information by telephone, , letter, fax or form. I understand that the cancellation of this authority must be made in writing or by telephone. Cancellation will not be effective until received and processed by ACC. SIGNATURE Client name: [Client full name] Date: Signature: The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code ACC5937 FEBRUARY 2012 PAGE 1 OF 1

12 CLIENT CONTRIBUTION GUIDE (Keep for your records) Due to the changing economic climate we have experienced a down turn in funding from Community Funding Groups on whom we depend to provide a low cost service. Please note that while we provide a low cost service, in that we don t charge an hourly fee for our time, we do ask clients to provide a contribution from entitlements received from ACC following our intervention on your behalf. Revoked decision prior to Review $150 Revoked decision prior to Appeal $250 Reinstatement of Weekly Compensation $250 Accepted Surgery Requests $500 Payment of back dated Independence Allowance Lump Sum or Weekly Compensation 10% Photocopying costs for Reviews & Appeals Suggested Contributions PLEASE NOTE: ALL CONTRIBUTIONS CAN BE CLAIMED FOR ON AN IR526 FORM AND YOU WILL RECEIVE 33.33% BACK OF YOUR DONATION e.g. $150 DONATION, YOU WILL RECEIVE $50 BACK!! THIS GUIDE WILL NATURALLY DEPEND ON EACH INDIVIDUAL CASE AND SITUATION. WE RUN TOTALLY ON FUNDING AND DONATIONS AND WITH THE ECONOMY THE WAY IT IS, WE RELY MORE NOW THAN EVER ON CLIENTS DONATING DUE TO THE LACK OF FUNDING AVAILBLE. WITHOUT THIS WE CAN NOT CONTINUE TO HELP CLIENTS AS WE HAVE SUCCESSFULLY HELPED TO DATE! Please note: The requested donations above are separate from your individual responsibility of costs when obtaining fresh medical opinions and GP notes etc. Please also note that when you are requested to obtain certain information for the office that this is done in a timely manner to ensure that consistent flow is made with your case. WITH THANKS THE AIST TEAM

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