Service Agreement Lodgement Form

Service Provider Allocated Budget Request

This form is used to advise Click Plan Management of current service agreements in place with your participant. Click Plan Management will create specific allocated budgets based on the information provided. If we envisage a problem with this allocation we will liaise directly with the participant, their plan nominee or Support Coordinator accordingly.
CONSENT

Providers are responsible for ensuring that they have the appropriate consent in place prior to sharing information.
Provider Details
Provider Name*
Contact Person

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Participant's Details
Participants Name*

First NameLast Name
NDIS Number*
Date of Birth*

DayMonthYear
Date
Plan Start Date*

DayMonthYear
Date
Plan End Date*

DayMonthYear
Date
Allocation of Funding

Please complete the below section.
Service Agreement Start Date*

DayMonthYear
Date
Service Agreement End Date*

DayMonthYear
Date

Budget Breakdown*

	Yes Or No	Total Amount to Allocate for Service Agreement Period
Core - Assistance with Daily Life
Core - Assistance with Social and Community
Core - Transport (Activity Based)
Core - Transport (Provider Travel)
Core - Consumables
Capacity Building - Improved Daily Living
Capacity Building - Increased Social & Community Participation
Finding and Keeping a Job
Improved Relationships
Improved Health & Wellbeing
Improved Learning
Improved Living Arrangements
Support Coordination
Capital - Assistive Technology
Capital - Home Modifications

Disclaimer:

As you would be aware due to privacy Click Plan Management is unable to inform providers directly regarding participant funding information, Click will liaise with the participant or their representative accordingly. Further, whilst Click will endeavour to support the participant or their representative to effectively manage their budgets, there are many variables outside our control that can impact the availability of funds. Therefore, Click makes no guarantee regarding the availability of funds noted in the service/funding agreement.
File Upload Area

Please upload a copy of your signed service agreement with the participant. Please note: Only signed service agreements will be accepted
Service Agreement - Signed*

Cancelof
Schedule of Supports

Cancelof
Additional Document

Cancelof
Should be Empty:

Service Provider Allocated Budget Request