Consent To Share Information Form

Consent to share your information

Please complete and sign this form to give the National Disability Insurance Agency (NDIA) permission to share your information on your behalf. The information we will share will depend on the permission you give us on this form. For example, you can agree to us sharing information to a third party about:

· you

· your plan or your funded supports

You do not have to give your permission if you do not want to share your information. If you give us permission and then decide that you don’t want us to share your information anymore, you can withdraw your consent by contacting us. You can do this in writing or verbally.

We will not share your personal information to anyone unless you have given your permission or the disclosure of your information is required or authorised by law.

Note: You can provide your consent to share your information with up to three people and/or organisations on this form.

How do I return this form?
Once you click the submit button, this online form will automatically be sent to our office.

Part A: Participant details
Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please complete this section about the participant you are representing.

Participants name

First NameLast Name

Participants date of birth

Date

NDIS Number

Preferred contact details (phone number, email address, etc.)

Part B: Child representative, plan nominee, legally appointed decision maker details

Please provide your details in this section if you are completing this form on behalf of a participant:

under 18 years for whom you have parental responsibility, or a child representative

for whom you are a plan nominee, or

for whom you are a legally appointed decision maker (for example, a guardian).

The NDIA may ask you to provide confirmation that you are authorised to represent the participant and to verify your identity.

Please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision makerOther

Participant representatives full name

First NameLast Name

Preferred contact details (phone number, email address, etc.)

Part C: Third party details and consent
I consent to the NDIA giving information about me (or the participant I am representing who is identified in Part A of this form), to the following people and/or organisations.

Note: In this part, you can provide the details of up to three people and/or organisations.

Person and/or organisation

Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation

My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service providers

My NDIS information

A copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals and AspirationsA copy of my current NDIS Plan’s funding and supportMy NDIS ContactOther

Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

To discuss an enquiry, complaint or feedbackTo discuss a provider payment queryTo discuss a provider quote

Please mark the relevant box below to indicate the length of time you are providing the consent for

Ongoing (For the duration of our involvement with the participant)For the duration of my current NDIS plan

Part D: Your declaration

Please note: NDIS participants’ aged 18 and over have other options instead of signing this consent form.

If you are unable to sign in Part D, you may provide verbal consent to the NDIA, or

You can direct someone aged 18 and over to sign (your ‘delegate’) in the presence of a witness.

If you direct a delegate to sign on your behalf, your delegate and witness needs to complete Part E. Otherwise, please sign, below.

By signing this consent form:

I understand I can obtain further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. You can find this information on the NDIS website (ndis.gov.au/privacy).

I understand I have given the NDIA consent to give information about me to the third party or parties I have listed at Part C on this form so they can take the identified action/s on my behalf.

I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time.

Privacy and your personal information - Collection of your personal information

The National Disability Insurance Agency (NDIA) would like some personal information from you to simplify your engagement with the NDIS. Any personal information you provide to the NDIA is safe under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. You can also ask to see what personal information (if any) we hold about you at any time and can seek correction if the information is wrong.

Personal information use and disclosure

The NDIA will use your information to support your involvement in the NDIS.

The NDIA will NOT use any of your personal information for any other purpose, or disclose your personal information to any other organisations or individuals (including any overseas recipients), unless authorised by law or you provide your consent for us to do so.

The NDIA’s privacy policy describes

how we use your personal information.

why some personal information may be given to other organisations from time to time.

how you can access the personal information we have about you on our system.

how you can complain about a privacy breach, and how the NDIA deals with the complaint.

how you can get your personal information corrected if it is wrong.

You can find the policy at the NDIS website (ndis.gov.au/privacy).

Personal information storage

The NDIA uses an Australian Government computer system to store personal information. System users, other than NDIA staff, may at times be able to see your name when they perform program duties, however they can’t record, use or disclose information, and they will not know if you become an NDIS participant. State or territory government officials may also have personal information access as part of the agreement between governments to assist the states and territories in their NDIS evaluation.

Name of the person completing this form

First NameLast Name

Signature of the person completing this form*

Date completed

Date