Distinctability Service Agreement

Plan Management Service Agreement

This Service Agreement is made between the following two parties:

1. The Participant
Full Name*
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Postcode
Contact phone number
contact phone number
Email Address
example@example.com
NDIA #*
Current Plan Start Date*

DayMonthYear
Current Plan End Date*

DayMonthYear
Upload a copy of your plan here:

Or email us a copy planmanagers@distinctability.org.au
Cancelof
Nominee Contact Details or Person supporting you (If Applicable)
Full Name
Relationship to participant
Address
Contact phone number
Contact phone number
Email Address
example@example.com
Any special considerations?

Do you have a Support Coordinator supporting you?*

YESNO
Contact details of Support Coordinator (if Applicable):
Full Name
Provider
Address
Contact phone number
Contact phone number
Email Address
example@example.com
I give consent to share my plan with my Support Coordinator:

YESNO

Conditions of the service agreement
In signing this agreement, I confirm that*

I agree that Distinctability Services will act as a Plan Manager and provide the service listed in this document - service requested - for the duration of thisI understand that this agreement is ongoing and that it will cover my current and future NDIS plans.I understand that by providing an email confirming an invoice, that I am approving payment of that invoice.I understand that Distinctability Services will invoice me via the NDIS portal as detailed in service booking.I have read the terms and conditions of this service agreement.My questions have been answered to my satisfaction.
Responsible person's name*
Signature*

Clear
Date*

DayMonthYear
Your Email *
to receive a copy of this service agreement
Should be Empty: