Disability Allowance Form - New Zealand

S03 – OCT 20114
S03 – OCT 2011
Disability Certicate 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 persons 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 uPlease provide details below: No uPlease go to Registered Medical Practitioner
Verication
3. What is the nature of the persons 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)
Parkinsons 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 ...
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