NDIS Service Agreement for Continence Assessment

This National Disability Insurance Scheme (NDIS) service agreement is for
a participant in the National Disability Insurance Scheme (NDIS).

Participant Details*

First NameLast Name

NDIS Number*

Plan Dates*

Date of Birth*

DD/MM/YYYY

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone*

Email*

Please enter the details of your disability that the NDIS have accepted

What is the reason for the continence assessment?

E.g., night wetting, day wetting, leaking pad, soiling, NDIS report etc.

Do you wear a continence product currently? If so, please indicate type here.

We will bring samples for you to the visit- please indicate either your current pad size and measurements (if it fits) underwear size, waist size or weight for appropriate samples to be selected.

How do you get around?

E.g., walk, walking stick, wheelchair, bed bound, hoist etc.

How do you communicate?

E.g., verbal, some words, sounds and gestures, non-verbal etc.

Contact details of person completing this form*

Name

Email and/ or phone*

Phone and email

Relationship to participant*

If you have a support coordinator (different from person above) please add their details here

Summary

This Service Agreement is made for the purpose of providing therapy/support services under the participant’s 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 independence and social and economic participation of people with 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

The provider agrees to provide the participant with specialist continence services which may include any of the following- thorough assessment, product recommendations, product prescription, quote for products, report for NDIS plan and care planning to support ongoing continence care provided by family or support workers.

The supports and their prices are set out in the attached Schedule of Supports. All prices are exempt from GST and include the full cost of providing the support.

Services requested on public holidays will be by negotiation.

Responsibilities of Practice

Melinda Webb Support Services agrees to:

review the provision of therapy/support services on each occasion of service with the participant
once agreed, provide therapy/support services 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 treatment is provided
give the participant information about managing any complaints or disagreements and details of the provider’s cancellation policy
listen to the participant’s feedback and resolve problems quickly
give the participant a minimum of 24 hours’ notice if the provider must change a scheduled appointment to provide therapy/Support services
give the participant the required notice if the provider needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information)
protect the participant’s privacy and confidential information
provide support in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law
keep accurate records on the supports provided to the participant
issue regular invoices and statements of the therapy/Support services delivered to the participant as per the Terms of Business for Registered Providers.

Responsibilities of the participant/participant’s representative

The participant/participant’s representative agrees to:

inform the provider about how they wish the therapy/support services 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 therapy/support services being provided
give the provider a minimum of 24 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
give the provider the required notice if the participant needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information)
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

Melinda Webb Support Services will seek payment as per the NDIS Pricing Arrangements and Price Limits 2024-25.

All payments are due within 7 days of invoice date.

Please select your accounts manager*

Plan ManagedSelf ManagedNDIA Managed- unfortunately Melinda Webb Support Services is unable to provide services for people under NDIA management at this time, but this is something we are working on for the near future.

Please provide details here if different from person completing this form

Details of plan manager

Email of accounts manager if different from person completing this form

Email of plan manager

Changes to this Service Agreement

If changes to the treatment or their delivery are required, the parties agree to discuss and review this Service Agreement. The parties agree that any changes to this Service Agreement will be in writing, signed, and dated by both parties.

Ending this Service Agreement

Should either party wish to end this Service Agreement ahead of the timeframe outlined above they must give 1 months’ notice. However, if either party seriously breaches this Service Agreement the requirement of notice will be waived.

Feedback, complaints, and disputes

If the participant wishes to give the provider feedback, the participant can talk to Melinda Webb Support Services on 0402 882 076.

If the participant is not happy with the provision of therapy services and wishes to make a complaint, the participant can talk to Melinda Webb Support Services on 0402 882 076.

If the participant is not satisfied or does not want to talk to this person, the participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting ndis.gov.au for further information.

Goods and Services Tax (GST)

For the purposes of GST legislation, the Parties confirm that:

GST is not chargeable on NDIS related health supports
a supply of therapy/support services under this Service Agreement 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 therapy /supports are provided
and the participant will immediately notify the provider if the participant’s NDIS Plan is replaced by a new plan or the participant stops being a participant in the NDIS.

Cancellation Policy

We understand that circumstances change and there may be occasions when cancellation occurs.

As your service provider we will:

Give you 24 hours’ notice or more, if possible, of cancelling and where possible offer another time.

You the participant will:

Provide 24 hours’ notice, more, if possible, to us on: 0402 882 076. A voice message can be left, or a text message is also acceptable.
If you do not provide 24 hours’ notice or more, then the full fee for services will be required to be paid as per agreed method.

If you have any questions with regards to this policy, please contact us at: melindawebbsupportservices.com.au

Variations

This agreement is made between the above participant and Melinda Webb Support Services and is valid for the period of 12 months.

Current prices listed are in accordance with the current NDIS pricing guidelines. Should the price guidelines change during the period of this service agreement Melinda webb Support Services agrees to honour the pricing listed.

Travel

Travel outside 25 KM from our office in Frankston may be charged, if so, it will be $1.00 per KM as per the NDIS price guide.

Please select from either CAPACITY FUNDING or CORE FUNDING below-

Delivery of Health Supports by a Clinical Nurse Consultant 15_418_0114_1_3 $150.00 per hour @ 6 hours- CAPACITY FUNDINGContinence assessment, recommendations, product prescription and recommendations, quote(s) for products, report for NDIS. May also include care plan(s), letters for school, GP, etc. Please contact us for requirements outside these items/ time frames.

$900.00AUD Quantity

Total

$0.00AUD

For any problems completing this form, or to discuss anything else concerning this form, please contact Melinda Webb Support Services on 0402 882 076 or email us on admin@melindawebbsupportservices.com.au

Participant or Representative Sign Here*