FOOT HQ NDIS Service Agreement

If you have any queries please feel free to call (02) 8520 8818.

Please note: All fields must be completed or the Service Agreement may not be able to be processed. Please attach a copy of the Participant's NDIS plan if possible, to assist in ensuring approved consumables are supplied.

Participant Name

NDIS Number

Date Of Birth

Date

Who Is Arranging Payment Of Your Invoices?

Self Managed/ Provider / Agency Managed - Foot HQ

Please refer to the core supports section on the NDIS plan.

Contact Person

Contact Number

Email Address

example@example.com

Residential Address

Support Coordinator Name: (If Applicable)

Support Coordinator Contact Number: (If Applicable)

Support Coordinator Email: (If Applicable)

example@example.com

Plan Dates (DD/MM/YY)

Date

Start

End

The Provider agrees to: Once agreed, provide supports that meet the Participant's needs at the Participant's preferred times. Communicate openly and honestly in a timely manner. Treat the Participant with courtesy and respect. Consult the Participant on decisions about how supports are provided. Listen to the Participant's feedback and resolve problems quickly. Give the Participant the required notice if the Provider needs to end the Service Agreement. Protect the Participant's privacy and confidential information.

RESPONSIBILITIES OF PARTICIPANT / PARTICIPANT'S REPRESENTATIVE

Inform the Provider about how they wish the supports to be delivered to meet the Participant's needs. Give the Provider the required notice if the Participant needs to end the Service Agreement. Let the Provider know immediately if the Participant's NDIS plan is suspended or replaced by a new NDIS plan or the Participant stops being a participant in the NDIS. To provide adequate information to the provider so a service booking can be made and funds claimed whilst remaining under budget.

PAYMENTS
*Rates are per NDIA set prices*
$188.99 per hour of Podiatry [standard appointments are 1 hour]
$188.99 - Comprehensive report
$ 0.99/km or time travelled (charged at same hourly rate) by our providers to and from location of service to our clinic (Suite 1/28-30 Urunga Pde, Miranda NSW 2228) [applicable to home visit appointments]

Please note:

If Foot HQ is unable to claim the invoiced amount, the participant will be liable for the balance of the unclaimed invoices.

The provider is eligible to claim up to 100% of the agreed upon cost of service if less than 24hrs notice cancellation or no-show.

The Parties agree to the terms and conditions of this Service Agreement.

Provider Representative Name

Participant / Participant's Representative Name

Provider Representative Signature

Participant / Participant's Representative Signature

Date

FOOT HQ

NDIS SERVICE AGREEMENT

FOOT HQ