NDIS Service Agreement Form

NDIS Service Agreement Form

Cross Care
Name *

Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Date of Birth *

Day Month Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email: Support Coordinator/Plan Manager
example@example.com
This Agreement will start

Day Month Year
Date
This Agreement will end with the plan end date *

Agree
Cross Care will be conducting your services as your intermediary's and or service provider *

Agree
Please Select your Services:

Physiotherapy Occupational Therapy Speech Pathology Podiatry Psychology Exercise Physiology Hydrotherapy Dietetics/Nutrition Home Modification
NDIS Number - Starts with 43 *
Where will the service take place?

In Home (Must be 20 minute radius from the clinic in Smithfield 2164 ) In Clinic School Child Care Other (Please Specify below)
Other (please specify)
When would you be requiring a report?

As soon as possible Within 3 weeks Within 5 weeks Just before my plan end date Within 10 sessions
When is your plan end date?

Month Day Year
Date
The terms and conditions outline that if you cancel within 48 hours (2 business days) of your session it will be billed and claimed for 100% of the NDIS charge. This is inline with the NDIS practice standards. *

Agree
If you are booked for ongoing/repeated sessions ie. weekly, fortnightly or monthly and cancel more than one consecutive session and wish to keep your booking time - you will be charged 50% of the NDIS session rate for every future booking canceled consecutively. *

Agree
Agreed Number of Sessions based on NDIS rates: *

Weekly Sessions Fortnightly Ongoing
COST Schedule of Supports (Breaks down what you are getting in terms of service)

Cross Care will follow the current NDIS price guide which can vary between $193.99 for Therapeutic Support or $214.41 For Psychology sessions.

Travel rates are calculated on the above charges and are limited to 30 minutes. This is subject to change depending on updated price guides from year to year.

This will be applied and calculated based on the number of services received.

To find out more regarding the NDIS Price guide please follow the link provided:

https://www.ndis.gov.au/providers/pricing-arrangements#ndis-pricing-arrangements-and-price-limits
Cost Breakdown *

I understand
The number of sessions required will depend on the therapists assessments/diagnosis and reports, and may change due to the clients needs throughout the duration of the plan: *

Agree
The session and travel rates are governed by the NDIS pricing guide. Travel charges depend on the location that the therapist is travelling from. *

I understand
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Signature *

Clear
Name of Advocate/Guardian if signing on the Participants behalf:
Cross Care - PARTICIPANT CONSENT DOCUMENT
EXCHANGE AND RECEIVE INFORMATION

Cross Care will keep your information private and confidential in a secure and safe place which will only be used by staff who support you and have permission to use it. The information that we exchange and receive will not be used for any other purpose other than assisting us in obtaining the appropriate help for you. I give permission for Cross Care to exchange and collect information on my behalf for accessing support, gaining assistance or advice and continuous improvement from other service providers, agencies and government departments. Some of these services may include:
Carers/guardians/support people Treating health professionals Travel agents or tour operators Other community and business services Auditors Department of Disability NDIS Quality and Safeguard Commission Schools and school teachers There may be circumstances where your personal information may be shared with a third party for mandatory reporting purposes without consent being sought All the above
EXCHANGE AND RECEIVE INFORMATION

Select All and Agree
DUTY OF CARE

Agree
DUTY OF CARE

I understand that I am required to adhere to the event hours and that Cross Care will not provide supervision outside of these times. I agree that I will not arrive more than 15 minutes prior to commencement and will leave no more than 15 minutes after completion of an event/session.
MEDICATION

If you require any medication to be administered it must be packed in its original form(container/packaging) or Webster packs, please make sure the Webster packs are secure and 3 days extra medication is packed in case of unforeseen circumstances.)
If you self-administer it must be in accordance with your doctors or manufacturer’s directions and you must advise Cross Care staff what medication you are taking in case of an emergency.

I require Cross Care staff to give medication to and hereby give permission to Cross Care staff to administer the required medication.
MEDICATION

NOT APPLICABLE Agree
DRUG AND ALCOHOL

I understand that I am not permitted to be under the influence, consume, use or distribute alcohol and drugs whilst on the activities of Cross Care.
DRUG AND ALCOHOL

Agree
HEALTH AND SAFETY RULES

All persons at Cross Care including staff and participants have the responsibility to:
· Behave and act in a safe, pleasant and responsible manner whilst on all activities.
· Respect the rights, welfare and diversity of the group.
· Take care of any equipment and property.
· Report any hazards or safety issues and tell a staff member immediately.

· Inform AEP staff if you or any other person requires first Aid and report any injuries to staff.
I understand that I am required to adhere to the health and safety rules set out above.
HEALTH AND SAFETY RULES

Agree
Client's Signature or independent advocates signature

Clear
Should be Empty:

NDIS Service Agreement Form

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Cross Care - PARTICIPANT CONSENT DOCUMENT