NDIS Service Agreement Terms

NDIS Service Agreement Terms

Acknowledgement
Client Details
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Parent/Carer/Plan Nominee/EPOA Details

If Applicable
Name

First NameLast Name
Relationship to Client
Phone Number
NDIS Plan Details
NDIS Number*
Funding Type*
Plan Start Date*

MonthDayYear
Date
Plan End Date*

MonthDayYear
Date
Email for invoices*
Email for Service Agreement*
example@example.com
Please contact us if your plan goes into review within the above dates.
Acknowledgement
Please review the following statements before signing this agreement:
- I agree that the details I have provided are true and correct.
- I have read and agree to the NDIS Service Agreement Terms.
- I have read and agree to the fees and charges, including all associated travel and cancellation fees set out within the fee schedule.
- I know and understand the avaiable avenues to lodge a complaint regarding the services being provided to me if I wish to do so.
- I confirm that I am the client, their Enduring Power Of Attorney, or plan Nominee. *Note* If you are the EPOA you will need to be enacted to pursue decision making for the client.
I hereby Acknowledge that I have read and understood the information outlined above*

YesNo
Name*

First NameLast Name
Date*

MonthDayYear
Date
Relationship*
Signature*

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A copy of Shine Alliance's service agreement is provided below
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Client Details