Disability Allowance Form - New Zealand
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.
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Disability Allowance Form - New Zealand PDF
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