FIRST VISIT - Consent to Share Information with MTH

I First Name Last Name of address Street Address Address Line 2 City State Zip authorise Made To Help Pty Ltd, NDIS provider Number 4050085679, to contact Enter NDIA, plan manager, doctor, etc to request my personal record or information consisting of:

Select which applies

I understand the purpose for disclosing my personal information to the person or organization noted above. I understand that I can refuse to sign this consent form or later withdraw my consent and I understand that refusal to sign or the withdrawal of consent could affect the ability of the requesting agency to provide services to me. Collection of this information complies with the National Disability insurance Scheme Act 2013 and Privacy Act 1988. I understand a copy of this document should be provided to the person providing the consent.

Participant/Nominee Signature

Signature Name

First NameLast Name

Date Signed

Date

If you are not the participant, please mark the relevant box below to indicate your relationship to the participant

Update Support Coordinator

Evidence if required.

Consent to Obtain/Share Personal Records or Information