Fillable Printable Disability Allowance Form - New Zealand
Fillable Printable Disability Allowance Form - New Zealand
Disability Allowance Form - New Zealand
1S03 – OCT 2011
CLIENT NUMBER
Q4 note: Please tick one box to
show the title you want to be
known by.
Name
Who can get
Disability Allowance?
Disability Allowance Application
If you, or a family member, have a disability, likely to continue for at least six months, you may
be able to get extra help through a Disability Allowance.
We may be able to help with costs such as ongoing visits to the doctor, medicines, medical
alarms and travel.
Your doctor or specialist will need to complete the Disability Certicate.
If you need help with this form call us on
%
0800 559 009.
Please read this
before you start
Please complete all questions – if not applicable write N/A.
1. What is your name?
First name(s)
Surname or family name
2. Are you known by or have you used any other names?
No Yes
u
Please provide details below:
1.
2.
3. Are you: Male Female
4. What do you want to be called?
Mrs Miss Ms Mr No title Other
Birth date
5. What is your date of birth?
Day Month Year
Address
Q6 note: If you live in a rural area,
a house number could include:
RAPID number •
re number •
emergency services number. •
Q7 note: Mailing address includes:
postal box (PO Box) •
rural delivery details •
C/O address. •
6. Where do you live?
Flat/house no. Street name
Suburb City
7. What is your mailing address (if different from above)?
If you live at a rural address please include your rural delivery details here:
8. How can we contact you?
Work phone Home phone Mobile phone
Email Fax
Q2 note: Give any other names that
you use now or have used in the
past (including your maiden name).
S03 – OCT 20112
S03 – OCT 2011
Expenses
Q17 note: You must provide invoices,
receipts, quotes or printouts for each
additional expense before they can be
considered as an ongoing cost for Disability
Allowance. These must be attached to this
form when you have completed it.
All of these expenses must be directly
related to the disability and veried
as necessary by a registered medical
practitioner.
Do not include costs that are covered by a
War Disablement Pension.
17. What additional expenses are paid for as a result of the disability?
How often Verication
List pharmaceuticals/items/services/treatments (eg daily, weekly, provided
(eg medical costs, gardening, transport, medical alarms) Cost? monthly)? (please tick 3)
$
$
$
$
$
Partner
Q9 note: A partner is your spouse
(husband or wife), your civil union
partner, or a person of the same or
opposite sex with whom you have a
de facto relationship.
9. Do you have a partner?
No
u
Are you: Single Living apart/ separated Divorced
Widowed Civil union dissolved
Yes
u
Are you: Married In a civil union In a relationship
10. What is your partner’s name?
11. What is your partner’s date of birth?
Day Month Year
Income
Q12 note: Examples of income from
other sources:
wages or salary •
accident compensation •
farm or business income (include •
drawings)
self employment •
interest from savings or investments •
dividends from shares •
income from rents •
redundancy or termination type •
payments
Child Support •
maintenance payments •
boarders •
Student Allowance, scholarship or •
Student Loan living cost payments
any other income, eg family trusts, •
overseas payments.
Give gross (before tax) amount.
12. Did you or your partner (if you have one) get income from any other source in the last 52
weeks?
No Yes
u
Please provide details below:
Source (eg bank account number) You Your partner Jointly
$ $ $
$ $ $
$ $ $
13.
Do you or your partner (if you have one) expect to get other income in the next 52 weeks?
No Yes
u
Please provide details below:
Source (eg bank account number) You Your partner Jointly
$ $ $
$ $ $
$ $ $
Disability Allowance
Q14 note: Please tick one box only.
You may be able to get Child
Disability Allowance for the same
dependent child. Please talk to us
about this.
Entitlements
14. Who are you applying for?
Yourself
u
Go to Question 15 Your partner
u
Please provide their full name below:
Your dependent child
u
Please provide their full name below:
First name(s) Surname Relationship to you
15. Is this disability covered by private medical insurance?
No Yes
u
Please provide details below:
16. Is this disability covered by ACC or War Disablement Pension?
No Yes
u
If ‘Yes’, you may not be entitled to a Disability Allowance
S03 – OCT 2011
3S03 – OCT 2011
Privacy Statement
The legislation administered by
the Ministry of Social Development
allows us to check the information
that you give us in this form.
This may happen when you apply
for a benet and at any time after
that.
Important
Obligations
Work situation changes include starting
part-time, casual or full-time work,
whether paid or unpaid.
Changes in your living situation include:
marriage or separation •
starting or ending a civil union •
starting or ending a de facto •
relationship with someone of the
same or opposite sex
change in the number of children •
supported
change in accommodation costs. •
The information I have given is true and complete. The conditions for receiving this assistance have been explained to me and
I understand these conditions. I am also aware of and understand the Privacy Act statement contained in this application form.
Client’s name (print) Client’s signature
Day Month Year
Partner’s name (print) Partners signature
Day Month Year
The Privacy Act 1993 requires us to tell you that:
The information you give us is collected under the authority of the legislation administered by the •
Ministry of Social Development.
The information will be held by the Ministry of Social Development.•
The information is collected for the purposes of the legislation administered by the Ministry of •
Social Development (including Work and Income, Child, Youth and Family and other service lines
of the Ministry), and in particular for:
– granting benets and other assistance under the Social Security Act 1964
– providing employment related services
– statistical and research purposes
– providing advice to Government
– care and protection needs of children
– providing support and services for you and your family
– providing education related services.
Work and Income may contact health providers to verify any health related information you give us.•
Work and Income may give employers information about you to nd you employment. Where •
Work and Income refer you to a job vacancy, we may also contact the employer to discuss the
result of any job interview that you attend.
Work and Income may share information you have given us with childcare centres to administer •
your entitlement to childcare assistance.
Other information that you give us on your skills, aspirations, family circumstances etc, and that •
is not required to assess your entitlement to a benet may be used to provide a better service to
you by the Ministry of Social Development.
The information you give us may be compared with information held by Inland Revenue, the •
Ministry of Justice, the Department of Corrections, the New Zealand Customs Service, the
Department of Internal Affairs, the Accident Compensation Corporation, Housing New Zealand
Corporation, Ministry of Health and Immigration New Zealand. It may also be compared
with social security information (for example, pension or benet information) held by other
governments (including Australia and the Netherlands).
Under the Tax Administration Act 1994, if you have dependent children, the information you give •
us may be shared with Inland Revenue for the purpose of administering Working for Families Tax
Credits. Inland Revenue may also:
– use the information for the purposes of child support, student loans and taxation
– disclose it to the Department of Labour, Statistics New Zealand, the Ministry of Justice, the
Accident Compensation Corporation, and the Ministry of Education
– disclose your personal information to your partner.
Under the Privacy Act 1993 you have the right to ask to see all information we hold about you, •
and to ask us to correct that information.
You are not required to give us information, but if you do not give us all the information we ask •
for, your application for benets may be declined.
I must tell Work and Income immediately if either my partner or I:
have a change in work situation•
become self employed / start to run a business•
have changes to my / our income or nancial circumstances•
intend to travel overseas•
start / nish part-time or full-time study•
have changes to personal details (such as name, address or bank account details)•
have changes to my / our living situation•
am imprisoned / held in custody on remand•
am admitted to or discharged from hospital•
have been granted an overseas pension•
have any other changes that may affect my / our benet entitlement or rate.•
I understand that:
if I have made a false statement • or
if I have failed to answer all the questions in full • or
if I do not tell Work and Income about changes in my life that might affect my entitlement or rate•
then
my benet may be reviewed and cancelled • and
I may have to pay back the total amount of any overpayment that I have received • and
Work and Income may impose a penalty (up to three times the value of the overpayment) • or
I may be prosecuted and ned or imprisoned.•
S03 – OCT 20114
S03 – OCT 2011
Disability Certicate Registered Medical Practitioner to complete
CLIENT NUMBER
The Disability Allowance is available for reimbursement of additional costs arising from a
Disability where the following criteria is met:
1. The person has a disability which is likely to continue for not less than six months; and
2. The disability has resulted in a reduction of the person’s independent function to the extent
that:
the person requires ongoing support to undertake the normal functions of life, or •
the person requires ongoing supervision or treatment by a registered health professional •
.
For the purposes of qualifying for Disability Allowance, a disability means:
physical disability or impairment •
physical illness •
psychiatric illness •
intellectual or psychological disability or impairment •
any other loss or abnormality of psychological, physiological, or anatomical structure or •
function (including sensory impairment)
reliance on a guide dog, wheelchair, or other remedial means •
the presence of the body of organisms capable of causing illness. •
For more information about Disability Allowance, refer to the “Guide for Medical Practitioners
– Disability Allowance” brochure.
2. Does the person have a disability that meets the Disability Allowance criteria?
Yes uPlease provide details below: No uPlease go to Registered Medical Practitioner
Verication
3. What is the nature of the person’s disability?
Please tick the major disabilities or specify below:
Please read this
before you start
Name
1. What is the client’s name:
First name(s)
Surname or family name
Psychological or psychiatric conditions
Stress (160)
Depression (161)
Bipolar disorder (162)
Schizophrenia (163)
Other psychological/psychiatric (165)
Nervous system disorders
Epilepsy (120)
Multiple sclerosis (121)
Parkinson’s disease (122)
Muscular dystrophy (123)
Other nervous system disorders (124)
Cardio-vascular disorders
Heart disease (130)
Stroke (131)
Other cardio-vascular (132)
Immune system disorders
HIV / Aids (140)
Other immune system disorders (141)
Metabolic and endocrine disorders
Diabetes (150)
Other metabolic or
endocrine disorders (151)
Substance Abuse
Alcohol (170)
Drug (171)
Other substance abuse (172)
Sensory disorders
Blindness (180)
Other visual / eye (181)
Hearing / ear (182)
Other sensory disorders (183)
Disability details
continued overleaf ...
S03 – OCT 2011
5S03 – OCT 2011
Verication of doctor
or specialist visits
Items / services /
treatments /
pharmaceuticals
Registered Medical
Practitioner’s
verication
4. Please indicate the expected duration of the disability:
Less than 6 months
u
There may be no entitlement to Disability Allowance
6 to 12 months 1 to 2 years 2 to 3 years Permanent
u
Never reassess
6. Please list the pharmaceuticals, items, services or treatments that are necessary and of
therapeutic value for the stated disability:
Registered Medical
Item / service / treatment / pharmaceutical
Practitioner’s initials
5. Please list the type, cost and how often visits to doctors or specialists are necessary
and result from the stated disability:
How often (eg daily, Registered Medical
Type of consultation Cost weekly, monthly)?
Practitioner’s initials
$
$
$
Accident
Burns (190)
Fractures, dislocations, soft tissue
injury (191)
Poisoning, toxic effects (192)
Internal injuries (193)
Injury to the nervous system (194)
Back pain / injury (195)
Overuse injury [RSI] (196)
Complications of medical or surgical
care (197)
Other injury (198)
Other disorders
Congenital conditions (103)
Intellectual disability (164)
Cancer (104)
Infectious / parasitic diseases (105)
Musculo-skeletal system disorder (106)
Respiratory disorders (107)
Genito-urinary disorders (108)
Blood and blood forming organs (109)
Skin disorders (110)
Digestive system disorder (111)
Please print your details below.
HPI number
Medical Practitioner’s full name
Practice name and address
Telephone number ( )
Medical Practitioner’s signature
Day Month Year
This information is required under the Social Security Act 1964.
Privacy Act: The person has been advised and understands that this information is required for
benet assessment purposes.
S03 – OCT 20116
OffICE USE ONLy
Statement by Interviewing / Interpreting Ofcer
I have explained the conditions for receiving a benet and explained what the client’s obligations mean and the reason for them. The client has
indicated that he / she understands and accepts responsibility to provide true and complete information and to advise immediately of any changes in
circumstances. All questions have been completed.
Name (print) Interviewer’s signature
Day Month Year
Additional information:
Decision:
Processor’s signature
Day Month Year
Authenticator’s signature
Day Month Year
10% 100% Critical data Checker’s signature
Day Month Year
Bring up B f
Day Month Year
Printed in New Zealand on paper sourced from well-managed sustainable forests using mineral oil free, soy-based vegetable inks
