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ACC Request for Transport Costs Phone 0800 101 996 for information or assistance IMPORTANT INFORMATION Before you complete this form please read the fact sheet Travel to treatment or rehabilitation which outlines the details on what help you may be eligible for. Payment of or contribution to your expenses can only be considered if all the details requested are provided. PLEASE ATTACH A BANK DEPOSIT SLIP OR LETTER FROM YOUR BANK THAT GIVES YOUR BANK ACCOUNT NUMBER CLAIMANT DETAILS Name Claim number Physical address Date of injury Date of birth Postal address if different TRAVEL TO TREATMENT/REHABILITATION DETAILS For calendar month 20 Date Travel from Type of treatment Attach tickets or receipts for any travel by scheduled public or other non-private transport. Payment of or contribution to your expenses can only be considered if all the details requested are provided. PLEASE ATTACH A BANK DEPOSIT SLIP OR LETTER FROM YOUR BANK THAT GIVES YOUR BANK ACCOUNT NUMBER CLAIMANT DETAILS Name Claim number Physical address Date of injury Date of birth Postal address if different TRAVEL TO TREATMENT/REHABILITATION DETAILS For calendar month 20 Date Travel from Type of treatment Attach tickets or receipts for any travel by scheduled public or other non-private transport. Prior approval from ACC is required for contributions to the actual costs of other non-private transport e.g. taxi please call 0800 101 996 to seek prior approval. Treatment/Rehabilitation provider s name location and signature Total kms travelled Fare km See the fact sheet Travel to treatment or rehabilitation for details of the criteria for payments. Total DECLARATION Claimant s declaration I declare that the information on this form is correct and that I have not withheld any information likely to affect this request for travel costs. ACC Request for Transport Costs Phone 0800 101 996 for information or assistance IMPORTANT INFORMATION Before you complete this form please read the fact sheet Travel to treatment or rehabilitation which outlines the details on what help you may be eligible for. Payment of or contribution to your expenses can only be considered if all the details requested are provided* PLEASE ATTACH A BANK DEPOSIT SLIP OR LETTER FROM YOUR BANK THAT GIVES YOUR BANK ACCOUNT NUMBER CLAIMANT DETAILS Name Claim number Physical address Date of injury Date of birth Postal address if different TRAVEL TO TREATMENT/REHABILITATION DETAILS For calendar month 20 Date Travel from Type of treatment Attach tickets or receipts for any travel by scheduled public or other non-private transport. Prior approval from ACC is required for contributions to the actual costs of other non-private transport e*g* taxi please call 0800 101 996 to seek prior approval* Treatment/Rehabilitation provider s name location and signature Total kms travelled Fare km See the fact sheet Travel to treatment or rehabilitation for details of the criteria for payments. Total DECLARATION Claimant s declaration I declare that the information on this form is correct and that I have not withheld any information likely to affect this request for travel costs.

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