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Practitioner Email Notes to ParticipantThis will not be shown on the completed form.

Practitioner Email Notes to NomineeThis will not be shown on the completed form.

NDIS Service Agreement

This Service Agreement is for:

Service Period

Start Service Date *eg. Participant NDIS Plan start date

Finish Service Date *eg. Participant NDIS Plan end date

WeeksRounded down to nearrest whole week.

Provider

Organisation

Primary Practitioner *

Clinic Address

Practitioner Email

Who is completing this form

ParticipantNominee

Nominee

Type

Plan nomineeCorrespondence nominee

First Name *

Last Name *

Phone *

Email *

Participant

Date Of Birth *

First Name *

Surname Name *

Participant Phone *

Participant Email *

Participant Street address

City

State

Postcode

NDIS Plan

NDIS Number *

Plan End Date *

Upload NDIS Plan

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Note: The NDIS plan to be uploaded using the button, or emailed to info@physiohealthcorrimal.com.au

NDIS Plan Management

Management *

SELF MANAGEDNDIA MANAGEDPLAN MANAGED

Start Date *

Reference *

Plan Manager Organisation *

Plan Manager First Name *

Plan Manager Last Name *

Plan Manager Email *

Plan Manager Phone *

Support Coordinator First Name

Support Coordinator Last Name

Support Coordinator Email

Support Coordinator Phone

Schedule of Supports

Service

Profession

Location *

ClinicHome

Weeks

Support Item Number *

01_720_0118_1_3 Assessment Recommendation Therapy or Training - EC - Physiotherapist01_721_0128_1_3 Assessment Recommendation Therapy or Training Supports - Physiotherapist10_055_0128_5_3 Employment Related Assessment, Counselling and Advice - Physiotherapist15_003_0118_1_3 Early Childhood Intervention Professional - Physiotherapist15_055_0128_1_3 Assessment Recommendation Therapy or Training - Physiotherapist

Support Item Number *

12_027_0126_3_3 Advice provided by an Exercise Physiologist regarding exercise required12_027_0128_3_3 Advice provided by an Exercise Physiologist regarding exercise required15_200_0126_1_3 Assessment Recommendation Therapy or Training - Exercise Physiologist15_200_0128_1_3 Assessment Recommendation Therapy or Training - Exercise Physiologist15_609_0118_1_3 Early Childhood Intervention Professional - Exercise Physiologist

Notes:

Correct selection support item number is required - this will be included on invoices.
The Participant (incl. Nominee and Plan Manager if relevant) is required to confirm available budget.

Initial

Individual

Class *

* Note this is a budget estimate only. The rate for group activities is not fixed and is adjusted based on the number of participants.
Therefore rates invoiced may vary from $23.19 to $153.32.

Report

Travel

Other

Comments:

Above is a budget estimate, and subject to change.
Rates will be adjusted if there is any change in the NDIS price guide during the service agreement period.

Additional Notes:Practitioner may add additional notes.. eg. proposed booking schedule.

General Conditions

Payment:

The Participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement.
The Participant will pay the invoice on the day of service.
After providing those supports, the Provider will send the Participant an invoice for those supports for the Participant to pay to seek reimbursement.

Payment:

The Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement.
After providing those supports, the Provider will claim payment for those supports from the NDIA.
If NDIA advises funding is unavailable, then the Participant will pay the Provider directly

Payment:

The Participant has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement.
After providing those supports, the Provider will claim payment for those supports from the Plan Management Provider
If the Participant decides to change the Plan Manager Provider, then the Participant must provide 1 month notice in writing to the Provider
The Participant will check funding with the Plan Management Provider to ensure funds available to pay
If the Plan Management Provide advises funding is unavailable, then the Participant will pay the Provider directly.

What you can expect of us:

The services outlined in the above support section
A clear explanation of this service agreement,
Inclusion of yourself in all decisions regarding your supports
Prompt notice if we intend to end the agreement
Availability of invoices and statements for all your supports
Adherence of all rules and laws that apply to the NDIS, including the National Disability Insurance Scheme Act 2013 and the National Disability Insurance Scheme Rules

What we expect of you:

48 hours notice for cancellation of appointments
If this is not adhered to, 100% of the allocated cost of the appointment will be charged
Prompt notice of any changes to your NDIS plan, or if you wish to stop using the NDIS

How to change a service agreement:

Both the participant and PhysioHealth must agree and sign off on any new changes to this service agreement
Any changes to this agreement must be completed in writing
This can be emailed to info@physiohealthcorrimal.com.au or mailed to PhysioHealth & Sports Injury Clinic 5/219 Princes Hwy, Corrimal NSW 2518

How to end a service agreement:

PhysioHealth requires 1 month notice for any cancellations of a signed service agreement.
Any cancellations to this agreement must be completed in writing
This can be emailed to info@physiohealthcorrimal.com.au or mailed to PhysioHealth & Sports Injury Clinic 5/219 Princes Hwy, Corrimal NSW 2518

What to do if there is a problem:

You can discuss any issues with your treating practitioner
You can take the matter further and contact Kylie Moffitt at PhysioHealth & Sports Injury Clinic by phone or 4207 9999 email kylie@physiohealthcorrimal.com.au

If your problem remains unresolved, you can contact the NDIA directly,

National Disability Insurance Agency (NDIA) 1800 800 110
You can also visit the NDIS Website - https://www.ndis.gov.au
Or visit our local NDIS office, 25 Atchison St, Ground floor and Level 2, Wollongong 2500 NSW

I have read & understood above General Conditions *