10 - X

10 - X

10 - X

Please fill out the additional details below to generate a completed ACC6273 Provider referral for pain management form. This form will be attached to the automated email you receive once you have pressed submit.
1. Client details

Known barriers or special considerations
Please note details, eg if a barrier, note any existing or recommended support

2. Referrer details

3. ACC contact details (if known)

4. Why I’m making this referral Please let us know why you’re making this referral for the Pain Management service. Include advice on how the clients current pain concern is linked to covered injury(s) 5. Service level required Please let us know the type of service required.
Service level
The Pain Management Service supplier will contact ACC to seek approval

Please send a copy of all reports to ACC

Please provide all supporting medical information available

Please send a copy of any reports

6. Injury details

Read code

7. Injury management and rehabilitation Describe the management and rehabilitation provided to date.
Type and number of treatments:

Current assistance:

Current daily activities:

Barriers or obstacles to return to work:

Relevant client specific issues:

8. Relevant contact details Please list who was involved with this client’s rehabilitation.
Contact person’s name
Phone number
Email address

Treating General Practitioner (GP)

Employer or school





9. Attached documents Please list all the documents you’re attaching to this referral. For example clinical notes, radiology reports etc.