Change of vendor details




Yüklə 42.98 Kb.
tarix16.04.2016
ölçüsü42.98 Kb.

Complete this form in order to update records held by ACC and/or to authorise eBusiness activity if you are an existing vendor providing goods or services to ACC. Please return this completed form to ACC Provider Vendor Registrations, PO 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 – Vendor information

1. Changing your contact information

Your vendor code:     

Your vendor name:     

You’ll find both of these on your remittance advice.

Date details will change:      

Please do not give us any private and confidential addresses as they may be visible on client records.

NB: If you don’t give us a work postal address then we will send letters and payment remittance advices to your physical address.



Current physical work address:      

Current work postal address:      

New physical work address:      

New work postal address (if different from physical address):      

Changes to your main organisational contact person and/or work phone, work email details

New contact name:      

New work phone number:      

New work mobile number:      

New work email address:      

New preferred contact method (tick one):

 Work phone number

 Work mobile number

 Work email address

 Post

Changes to your referrals contact person and/or work phone, work email details

New contact name:      

New work phone number:      

New work mobile number:      

New work email address:      

New preferred contact method (tick one):

 Work phone number

 Work mobile number

 Work email address

 Post

Changes to your payments contact person and/or work phone, work email details

New contact name:      

New work phone number:      

New work mobile phone number:      

New work email address:      

New preferred contact method (tick one):

 Work phone number

 Work mobile number

 Work email address

 Post




2. Access to eBusiness

I need access to:

 ACC eLodgement – to send ACC45 injury claim forms electronically – Please complete all of Section 2

 ACC eBusiness Gateway – to send ACC40 invoices electronically and perform online queries – Please complete all of Section 2

 None of the above. I intend to deal with ACC via post – Please go to Part B



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:      

Work 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:      

Work email address:      

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

 MedTech 32

 Houston Medical

 Account4it (Peak)

 Profile for Mac

 Gensolve

 MyPractice

 Other – Please specify:      

Which device do you use to get online?

 PC or laptop

 Mac

 iPad

 Tablet

 Other – please specify:      




3. Changes to bank details

Original pre-printed deposit slip attached: 




Current details

New details

GST number

     

     

IRD number

     

     

Bank account number

     

     

Bank account name

     

     

Tax exemption certificate – please suuply copy

     

     

Special tax codes – please supply copy

     

     


Part B – Conditions, declarations and signatures

4. Changes to authorised signatories

Please supply the names of any new authorised signatories who can approve change requests on behalf of your organisation and ask them to complete and sign this section. We ask for at least 2 signatories. However, if you’re a sole trader who has no other authorised signatories please go to section 5

Name:      

Work email address:      

Job title:      

Work phone number:      

Signature:

Name:      

Work email address:      

Job title:      

Work phone number:      

Signature:

Name:      

Work email address:      

Job title:      

Work phone number:      

Signature:

To remove an authorised signatory

Name of person to be deleted:      

Work email address:      

Job title of person to be deleted:      

Work phone number:      




5. 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.




6. Vendor 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.

Full name:      

Job title:      

Signature:

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.

ACC1534 October 2015 Page of 4


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©www.azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə