Vendor registration – new vendor details




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ACC111

Vendor registration – new vendor details


Use this form if you are a new vendor providing goods or services to ACC clients to register your organisation or sole practitioner as an ACC vendor. If you are a caregiver providing Home support services you should complete an ACC84 Social Rehabilitation payment authority instead. Please contact us on 0800 222 070 for this form.

Please return this completed application to ACC Provider Vendor Registrations, P O Box 30823, Lower Hutt 5040, or email registrations@acc.co.nz. If you need help or have any questions, please email us or call us on 04 560 5211.



Part A – Your information

1. Vendor details

Organisation name (trading name that will appear on your invoices)

     

Legal name (if different):

     

Legal status (registered company):

     

Primary service provided:

     

Physical address (if no postal address is provided, then this is the address letters and payment remittance advices will be sent to):

     

Postal address (if different from physical address):

     

GST registered?  Yes  No

GST number:      

IRD number:      

Main organisational contact person

Contact name:      

Work phone number:      

Mobile number:      

Email address:      

Preferred contact method (tick one):

 Work phone number

 Mobile number

 Email address

 Post

Referrals contact person, if different from above

Contact name:      

Work phone number:      

Mobile number:      

Email address:      

Preferred contact method (tick one):

 Work phone number

 Mobile number

 Email address

 Post

Payments contact person

Contact name:      

Work phone number:      

Mobile number:      

Email address:      

Preferred contact method (tick one):

 Work phone number

 Mobile number

 Email address

 Post



2. eBusiness

I need access to:

 ACC eLodgement – to send ACC45 injury claim forms electronically

 ACC eBusiness Gateway – to send ACC40 invoices electronically and perform online queries

 None of the above. I intend to transact with ACC via post



Digital certificates

 I’ll need to apply for a digital certificate for my vendor organisation and its users

 My organisation already has a digital certificate and the details are:

Organisation name:      

Contact name:      

Email address:      

 The below organisation already has a digital certificate and I authorise them to submit and query invoices using my ACC vendor ID allocated as part of this application

Organisation name:      

Contact name:      

Email address:      

If you have a practice management system, please tick to show which one

 MedTech 32

 Houston Medical

 Account4it (Peak)

 Profile for Mac

 Profile for Windows

 Filemaker Pro

 MyPractice

 ClinicAide

 Gensolve

 NZ Physio Pro

 Comrad

 Karisma

 Quick As

 Excellent

 Incisive

 Exact

 Titanium

 Other – Please specify:      

Which web browser do you use?

 Internet Explorer

 Chrome

 Firefox

 Safari

 Other – please specify:      

Which device do you use to get online?

 PC or laptop

 Mac

 iPad

 Tablet

 Other – please specify:      

What operating system do you use

 Windows 8

 Windows 7

 Vista

 XP

 OSX

 Other – please specify:      


Part B – Conditions, declarations and signatures

3. Documentation

Please attach a pre-printed bank deposit slip for the account you wish payment to be made to. We need these details to pay you.

Original pre-printed deposit slip attached: 




4. Authorised signatories

Please supply the names of authorised signatories who can approve change requests on behalf of your organisation and ask them to sign this form. We ask for at least 2 signatories however, if you’re a sole practitioner who can only has one signatory, please ask someone to sign this form as a witness.

Signature:

Name:      

Email address:      

Job title:      

Phone number:      

Signature:

Name:      

Email address:      

Job title:      

Phone number:      

Signature:

Name:      

Email address:      

Job title:      

Phone number:      

Signature:

Name:      

Email address:      

Job title:      

Phone number:      




5. Witness declaration for sole signatories

The witness cannot be an authorising signatory.

I confirm that I have identified the person who has signed as an authorised signatory, and their position, and that they have signed this form in my presence.



Name:      

Job title:      

Phone:      

Email address:      

Signature:

Date:




6. Conditions for doing business electronically with ACC

  • All forms transmitted electronically to ACC must be true and correct

  • Invoices must only be submitted for services provided to a client, in accordance with the provisions of the applicable ACC legislation or contract

  • ACC may cancel its permission for you to submit forms electronically at any time without liability for any costs or compensation by giving two weeks’ written notice

  • Forms must be submitted in line with the specifications and protocols notified by ACC from time to time

  • Adequate procedures must be put in place to ensure the ACC system security standards, as set out in ‘ACC Security Policy for Electronic Business’, are met.




7. Declaration

I declare that:

  • the information given in this application is true and correct

  • I have read, understood and accept the conditions specified in section 6

  • I am authorised to make this declaration on behalf of the organisation.

Name:      

Job title:      

Signature:

Date:




8. ACC office use only

Vendor code:      

Administrator:

Date:      

Validator:      

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.

ACC111 July 2014 Page of 4


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