NDIS Service Agreement

NDIS Service Agreement

For participants in the National Disability Insurance Scheme
- Between JUST LIKE PTY LTD (Just Like Home) ACN 634 095 908
  
  and
- Participant / Participant’s representative name
  
  First NameLast Name
- This service agreement will commence on
  
  DayMonthYear
  Date
- Contact information
- The Participant / the Participant’s representative contact details:
- Name
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- The provider’s contact details:
  
  Name: Angela Mathew
  
  Phone: 0447 54 34 34
  
  Email: ang@justlikehome.com.au
- Funding Management Type
- The Plan Managers contact details, or if self managed, payers contact details
- Name
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- Upload your NDIS Plan
  
  Only if it's handy and you can upload it.
  Cancelof
- Service agreement signatures
- Director/Company Secretary signature
- Director/Company secretary name
  
  First NameLast Name
- Director signature
- Director name
  
  First NameLast Name
- Participant/Participant representative signature
- Participant/Participant representative name
  
  First NameLast Name
- Participant name
  
  First NameLast Name
- Date of birth
  
  DayMonthYear
  Date
- NDIS Participant Number
- Preferred method of contact
- I consent to my Support Coordinator, Just Like Pty Ltd, sharing my information with the groups, organisations or people named below and selected by me with a check mark (tick) to be able to perform tasks to assist me in utilising my NDIS plan. I understand I can retract this consent at any time by giving written notice.
  
  Other
- Participant or Participant representative signature
- Participant or Participant representative name
  
  First NameLast Name
- Should be Empty:

NDIS Service Agreement

Contact information

Service agreement signatures