Support Request Form

1

Who is completing this form?Note: this form can only be completed by the participant or their nominated representative.

First Name

Last Name

2

What is your NDIS number?* This field is required.You can find your 9-digit NDIS number on your plan or myplace portal.

NDIS Number

3

If you purchase supports that are not in line with your plan or are not NDIS supports, you may be required to pay this money back to the NDIS.Do you accept?

YESNO

4

What is the support?* This field is required.

5

Q1. Do you need the support because of impairments that meet the disability or early intervention requirements?* This field is required.The NDIS supports you buy must be related to the impairments that meet the disability or early intervention requirements. You can’t use NDIS funding for supports that are not NDIS supports.

YESNO

6

Q2. Is the support likely to meet your needs?* This field is required.You are encouraged to explore supports before deciding what to buy, so you can get the best support available to you.

YESNO

7

Q3. Is the cost of the support reasonable?* This field is required.When you think about the benefit of the support, is the cost of the support reasonable? It should give you good value for money compared to other options.

YESNO

8

Q4. Can you afford the support within your support budget?* This field is required.Your NDIS funding needs to last for the length of your plan. The support you buy must fit into your budget.

YESNO

9

Q5. Is the support something that should be funded by the NDIS and not other government services?* This field is required.The NDIS only funds disability-related supports. Other services and supports like dental, health or hospital services, education, housing, and public transport are all provided by other government organisations.

YESNO

10

Q6. Is the support safe? * This field is required.

YESNO

11

Q7. Is the support legal?* This field is required.

YESNO

12

Acknowledgement* This field is required.By signing below, I declare that I have answered all questions truthfully and that all the information I have provided is accurate. I acknowledge that if the National Disability Insurance Agency (NDIA) deems any NDIS funded AT supports not reasonable and necessary and/or in accordance with my NDIS plan, I may be asked to pay it back.

Clear