Service Agreement and Privacy Policy

This Service Agreement is for:*

First NameLast Name
Preferred name/pronouns
Name Pronouns
NDIS no:*
Start date of current NDIS plan

DayMonthYear
Date
End date of current NDIS plan

DayMonthYear
Date
Date of Birth*

DayMonthYear
Participant Nominee (if applicable):

First NameLast Name
Provider:
Date for agreement to begin:

YearMonthDay
The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Participant's National Disability Insurance Scheme (NDIS) plan.

The Parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:
- support the independance, social and economic participation of people with a disability, and
- enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.
Schedule of Supports
Other:
Activity Based TransportAssistance with Daily Activities (Core)Assistance to Access Community (Core)Capacity Building - Improved Daily LivingCapacity Building - Early Childhood InterventionCapacity Building - Social & CommunityLevel 2 Support CoordinationLevel 1 Therapy AssistanceLevel 2 Therapy AssistanceLow Cost Assisted TechnologyProvider TravelSchool Leavers Employment Service/CB EmploymentSpecialist Behavioural SupportSpecialist Support CoordinationOther:
1. Supports to be provided:
Total hours: (support/hours)*
Frequency: (daily/wkly/frtntly/as required))*
Funded NDIS Plan support area/s: (eg Core supports/type; Capacity Building /type)
Hourly fee:   Hourly fee:
Total amount:   Quote for 12 month period
2. Supports (if more than one support/service):
Total hours: (support/hours)
Frequency: (daily/wkly/frtntly etc)
Funded NDIS Plan support area/s: eg Core supports/type; Capacity Building /type)
Hourly fee:   Hourly fee
Total amount:   Quote for 12 month period
3. Supports (if more than one support/service):
Total hours: (support/hours)
Frequency: (daily/wkly/frtntly etc)
Funded NDIS Plan support area/s: eg Core supports/type; Capacity Building /type)
Hourly fee:   Hourly fee
Total amount:   Quote for 12 month period
Term of this Service Agreement & Privacy Policy:
For: 12 months from the date of the Agreement.
Term of the Service Agreement & Privacy Policy
Charges
The supports and their prices are set out in the NDIS Pricing Agreement & Price Limits, which is available at:

ndis.gov.au/providers/pricing-arrangements

Diverse Learning's NDIS Supports & Fee Schedule summary, as at 1 October 2022, is attached.

All prices are GST inclusive (if applicable) and include the cost of providing supports.

Additional expenses, (eg. things that are not included as part of a Participant's NDIS supports) are the responsibility of the Participant/Participant's Representative and are not included in the cost of the supports.

Examples include entrance fees, event tickets, meals etc.

Non-face to face time charges are charged at a minumum of 15 minutes.

Examples of these charges include telephone calls, NDIS and general enquiries, emails, sourcing of services or programs etc on behalf of the Participant and/or their Participant's Representative.

Provider Travel charges apply for Capacity Building Supports provided further than 15 minutes from the registered Diverse Learning office.
Price list
Yes, I agree with the Service Agreement & Privacy Policy charges
Responsibilities of the Provider
The Provider agrees to:
- review the provision of supports at least 6 monthly with the Participant
- 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
- give the Participant information about managing any complaints or disagreements and details of the Provider's Cancellation Policy, if relevant
- listen to the Participant's feedback and resolve problems quickly
- give the Participant a minimum of 24 hours' notice (where possible) if the Provider has to change a scheduled appointment to provide supports
- give the Participant the required notice if the Provider needs to end the Service Agreement (see 'Ending this Service Agreement' for more information)
- protect the Participant's privacy and confidential information
- provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law
- keep, maintain and hold securely accurate records on the supports provided to the Participant, and
- issue regular invoices and statements of the supports delivered to the Participant.
- Work with the participant and their chosen network of supports, respecting the participants values, cultural considerations and upholding participant rights to choice and control.
Responsibilities of the Participant / Participant's Representative
The Participant / Participant's Representative agrees to:
- inform the Provider about how they wish the supports to be delivered to meet the Participant's needs
- treat the Provider with courtesy and respect
- talk to the Provider if the Participant has any concerns about the supports being provided
- give the Provider a minimum of 48 hours' notice if the Participant cannot make a scheduled appointment; and if the notice is not provided by then, the Provider's Cancellation Policy will apply (100% of the schedule service fee). 72 to 48 hours prior a 50 percent cancellation fee applies.
- give the Provider the required notice if the Participant needs to end the Service Agreement (see 'Ending this Service Agreement' for more information), and
- 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.
Payments
Management of NDIS Plan Funds
SELF MANAGED: IF THE FUNDING FOR ANY OF THE SUPPORTS PROVIDED UNDER THIS SERVICE AGREEMENT & PRIVACY POLICY IS MANAGED BY THE PARTICIPANT: The Participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement & Privacy Policy. After providing those supports, the Provider will send the Participant an invoice for those supports for the Participant to pay. The Participant will pay the invoice within 7 days from issue.AGENCY MANAGED: IF THE FUNDING FOR ANY OF THE SUPPORTS PROVIDED UNDER THIS SERVICE AGREEMENT & PRIVACY POLICY IS MANAGED BY THE NATIONAL DISABILITY INSURANCE AGENCY: The Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement & Privacy Policy. After providing those supports, the Provider will claim payment for those supports from NDIA.PLAN MANAGED: IF THE FUNDING FOR ANY OF THE SUPPORTS PROVIDED UNDER THIS SERVICE AGREEMENT & PRIVACY POLICY IS MANAGED BY A REGISTERED PLAN MANAGEMENT PROVIDER: The Participant has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement & Privacy Policy. After providing those supports, the Provider will claim payment for those supports from the nominated Plan Management Provider.Private/Non NDIS (GST May apply)
If multiple services with different management types - please describe which services are eg plan vs agency managed:
Name of the Participant's nominated Plan Management Provider:
Contact email for invoicing*
Contact details for plan manager*
Changes to this Service Agreement & Privacy Policy
If changes to the supports or their delivery are required, the Parties agree to discuss and review this Service Agreement & Privacy Policy.

The Parties agree that any changes to this Service Agreement & Privacy Policy will be in writing, signed, and dated by the Parties.
Ending this Service Agreement & Privacy Policy
Should either Party wish to end this Service Agreement & Privacy Policy, they must give one weeks notice.

If either Party seriously breaches this Service Agreement & Privacy Policy, the requirement of notice will be waived.
Feedback, Complaints & Disputes
If the Participant wishes to give the Provider feedback, the Participant can contact Diverse Learning's Complaints Team by:

Email: feedback@diverselearning.com.au

If the Participant is not satisfied or does not want to talk to this person, a complaint can be made to the NDIS Commission by:

Telephone: 1800 035 544 (free call from landline) or TTY 133 677 (interpreters can be arranged)

National Relay Service and ask for: 1800 035 544.

Website: https://www.ndis.gov.au/contact/feedback-and-complaints
Goods & Services Tax (GST)
For the purposes of GST Legislation, the Parties confirm that:
- a supply of supports under this Service Agreement & Privacy Policy is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the National Disability Insurance Scheme Act 2013 (NDIS Act), in the Participant's NDIS Plan currently in effect under Section 37 of the NDIS Act;
- the Participant's NDIS Plan is expected to remain in effect during the period the supports are provided; and
- The Participant / Participant's Representative will immediately notify the Provider if the Participant's NDIS Plan is replaced by a new Plan or the Particpant stops being a participant in the NDIS.
Privacy Information
Diverse Learning Pty Ltd is committed to complying with the Privacy Act 2001, the Australian Privacy Principals 2014 and the privacy provisions of all applicable legislation.

We are bound by the Privacy Act 2001 to obtain your written consent to collect personal information.

The purpose of collecting this inforamtion is to assist in creating the best outcome for your child.

We will only disclose personal information in accordance with the Privacy Act. This means that personal information may be disclosed for:
- the purposes for which we have advised that we are collecting it, and for related purposes that the individual would reasonably expect;
- where we have the consent of the individual to do so;
- as required by Law; or
- under other circumstances where permitted under the Act.
To effectively assist you, we must exchange information between the NDIA, your Providers and any other parties associated with you/your child's NDIS Plan.

Individuals will be able to access their personal information upon request.

However, Diverse Learning Pty Ltd may occasionally need to deny access to information in accordance with the expemptions contained in the Act.

Our goal is to protect the personal information collected by Diverse Learning Pty Ltd and its associations.

Personal information will be managed confidentially and securely, and destroyed appropriately when no longer required.

Privacy related inquiries or concerns can be directed to Diverse Learning's Privacy Officer by:

Email: info@diverselearning.com.au
Participant Contact Details
Participant Phone / Mobile number*
Participant's Representative Phone / Mobile:
Please enter a valid phone number.
Participant Email*
example@example.com
Participant's Representative's Email
example@example.com
Participant's Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Postal Address (if different to residential address):

Street Address

Street Address Line 2

SuburbState

Post Code
Provider Contact Details
Your main Diverse Learning Employee contact*
Please start typing contact name to select or ‘info’ if unsure
NDIS Quality & Safeguards Commission Audit
All NDIS providers are required to participate in regular auditing by the NDIS Quality & Safeguards Commission.

PLEASE NOTE: auditing of the Participant's files can be at your discretion, and you may opt out if your would prefer.
I would like to OPT OUT of participation in the NDIS audit process
Information Sharing Consent
It is the Participant / Participant's Representative's responsibility to provide relevant information from the NDIS Plan prior to services commencing with the Provider.

Diverse Learning Pty Ltd is a registered Provider with NDIS and our services can be claimed fully from NDIS Plan funding.

Please provide names and contact details for those individuals and/or organisations who you would like information to be shared with:
Contact Name & Details for Individuals & Organisations:*
DO NOT SHARE WITH:
Emergency and Disaster Planning
The Emergency Plan Agreement is developed to comply with NDIS standards that require providers, such as Diverse Learning, to understand how we would respond to the needs of each participant in an emergency and or disaster. This planning considers and mitigates risks that may arise in an emergency or disaster to participants health, wellbeing and safety. It also helps us ensure continuity of supports critical to the health, safety and wellbeing of participants in an emergency or disaster.
Medical equipment for health conditionsTemperature regulation issues without airconditioning eg health conditions or behaviour trigger.Access to cooking equipment and safely stored food due to restricted diet etc.I would be okOther
Call your emergency contactContact emergency services to alert them and do a wellbeing checkOther
Call your emergency contactAccess key safe if applicable/providedOther
I live with others, and have good informal supports.I live alone, but have a good network of informal supports I could call on in an emergency.I rely on formal supports, which would still be enough to meet my needs in an emergency.The supports I have would not be enough in an emergency, and I would need extra help.Other
What would you need extra supports with in an emergency? (Eg particular tasks, time of day, equipment?)*
Please let us know about your preferred contacts the event of any emergency.

e.g. Do you want one person to be contacted first? Do you have a second preferred contact person? Are there times when its best to call (e.g. Not during working hours etc.)? What actions do you authorise your contact to take?
Emergency/alternative contacts*
Service Agreement, Emergency response and Information Consent
Yes
Yes
Yes
Participant / Participant's Representative*

First NameLast Name
Signature*

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Date*

DayMonthYear
Authorised Provider Contact Date:

DayMonthYear
Date

Personal information (optional)

This information may help us to support you better, in emergency, community, medical or group settings - all questions are optional, please share any information you feel would be beneficial for us to understand your needs when providing services to you.
About You
Things you like/enjoy*
Important people to you/regular contacts/ who you live with*
Triggers/things you dislike*
Sensory issues*
Dietary requirements*
Assistance animals/pets*
Particular needs in an emergency/unexpected situation*
Plans in place eg PBS, transfer and lifting, swallowing. *
Medical information
Regular GP/Doctor, any health insurance and Medicare no (optional). *
Important health information/conditions*
Important medications/any allergies *
Do you have any guardianship/ court orders/enduring power of attorney/advance care directive/will in place and where they are accessible?*
Ambulance/emergency assistance

Please note that we may have a duty of care to call ambulance or for other emergency assistance if needed and you are unable to consent. We STRONGLY recommend you hold ambulance cover as we are not liable for the cost of an ambulance attendance should this be needed, this is your private expense.
YesNoDo not wish to disclose
Admin only notes section
Should be Empty:

Schedule of Supports

Term of the Service Agreement & Privacy Policy

Charges

Responsibilities of the Provider

Responsibilities of the Participant / Participant's Representative

Payments

Management of NDIS Plan Funds

Changes to this Service Agreement & Privacy Policy

Ending this Service Agreement & Privacy Policy

Feedback, Complaints & Disputes

Goods & Services Tax (GST)

Privacy Information

Participant Contact Details

Provider Contact Details

NDIS Quality & Safeguards Commission Audit

Information Sharing Consent

Emergency and Disaster Planning

Please let us know about your preferred contacts the event of any emergency.

Service Agreement, Emergency response and Information Consent

Personal information (optional)

About You

Medical information

Ambulance/emergency assistance