NDIS Service Agreement

NDIS Service Agreement

For participants in the National Disability Insurance Scheme

Service Agreement for NDIS participants
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*

Self ManagedPlan Managed
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

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Service agreement signatures
Director/Company Secretary signature

Clear
Director/Company secretary name

First NameLast Name
Director signature

Clear
Director name

First NameLast Name
Participant/Participant representative signature*

Clear
Participant/Participant representative name*

First NameLast Name

Consent to Exchange
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.*

Support ProvidersTherapistsPlan ManagerEmployment ServiceAllied Health PractitionersNoneOther
Participant or Participant representative signature*

Clear
Participant or Participant representative name*

First NameLast Name

Contact information