Diversity Plan Management Registration Form

Diversity Plan Management

info@diversityndis.com.au

www.diversityndis.com.au

0434 693 777
Diversity plan management - Registration Form
Welcome to Diversity Plan Management!

Thank you for the opportunity to support you with your NDIS plan. I look forward to working with you.

To commence the setup process, please complete the service agreement. I will reach out to you within 1 business day to provide updates about the onboarding process, outline the next steps, and answer any questions you may have.

Kind regards,
Erica Gilmore
Diversity Plan Management
You can complete this form on your phone, tablet, or computer. Once you have finished, you will receive a copy for your records. I will contact you shortly to discuss the next steps.
I. Participant Details
Participant Full Name*

First NameLast Name
Pronouns (optional)
E.g. Mr, Mrs, Ms, He, She, They, Them etc.
Date of Birth*

DayMonthYear
NDIS Number*
Plan Start Date*

DayMonthYear
Date
Plan End Date*

DayMonthYear
Date
Email*
Where the confirmation will be send to
Phone Number*
mobile or landline phone number including area code
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Do you require an interpreter for phonecalls / meetings?
What language do you require?
E.g. Auslan, Mandarin etc...
Authorised Representative (if any)
Authorised Representative Name

First NameLast Name
Relationship to the participant
E.g. Parent / Guardian / Support Coordinator
Email
Email address for nominee / Authorised Representative
Phone Number
Best number to contact you on
Our fees
As a Plan Managed participant, the NDIS provides funding in your plan to cover all your plan management fees. Monthly fees will be invoiced to your plan according to the NDIS Price Guide. The fees for my service are:

Monthly fee $104.45
Invoice Approval Options
I'm here to make managing your NDIS plan as simple as possible while ensuring you maintain control over how things are managed.

Please let me know if you would like me to automatically accept and pay any invoices that meet NDIS requirements, or if you prefer to review and approve each invoice before payment.
Invoice Approvals*
Attach a copy of your plan (optional)
Optional - Upload Plan

Cancelof
Participant or Authorised Representative Signature
By signing the space below, you agree to join Diversity Plan Management, and confirm that the information provided in your registration is true and correct, and that you are signing as the participant or with the appropriate authority as their Authorised Representative.
When you press the submit button, you will receive an email confirmation that your application was received. Please retain a copy as verification of your registration. I will contact you to confirm your registration within 1 business day.
You may contact me at any time at info@diversityndis.com.au, or on 0434 693 777 or 03 9125 6611.
Signature*
Should be Empty:

Diversity plan management - Registration Form

I. Participant Details

Our fees

Invoice Approval Options

Attach a copy of your plan (optional)

Participant or Authorised Representative Signature