Skin Colour Change – Assessment Questionnaire

I confirm that the information I have provided in this questionnaire is true, complete, and accurate to the best of my knowledge.

I understand that this questionnaire is used to assist in the clinical assessment of my condition and to support a potential application for funding through the Accident Compensation Corporation (ACC). Completion of this form does not guarantee acceptance of any claim or approval of funding for consultation, procedures, or ongoing treatment.

ACC Funding & Clinical Assessment

I acknowledge that:

• All funding decisions are made solely by ACC in accordance with their policies, clinical criteria, and assessment processes.
• My treating Dermatologist will undertake an independent medical assessment and may determine whether my presentation is consistent with an accident-related injury.
• Additional supporting information (including clinical photographs, reports, or specialist opinions) may be required to support my claim.

Consent to Use and Share Information

I consent to:

• The collection and storage of my personal and health information for the purposes of clinical care and ACC claim preparation.
• The use of clinical photography where relevant for documentation and submission to ACC.
• The sharing of relevant medical information with ACC and other healthcare providers involved in my care, in accordance with the Privacy Act 2020 (New Zealand) and applicable health information standards.

Treatment, Outcomes & Financial Responsibility

I understand that:

• Treatment recommendations are based on clinical assessment and may evolve over time.
• No guarantees can be made regarding treatment outcomes, including improvement in scar appearance or skin colour changes.
• If ACC funding is declined, delayed, or only partially approved, I may be responsible for some or all costs associated with consultations, procedures, and ongoing care.

Medico-Legal Clarification

I understand that this questionnaire reflects my self-reported history and symptoms and does not, in itself, constitute a medico-legal determination of injury causation, treatment necessity, or eligibility for ACC cover.