ISM's Product Procurement Request

Product Procurement Request Form
Your Details

ISM needs your details and contact information for NDIS verification and ISM record purposes. The information you provide is encrypted and private and will never be shared with any third-party without your consent.

Our Product Procurement Service

ISM’s Product Procurement Service request form is used to provide you with services and gives us permission to work with you and your NDIS plan.

If you wish to sign up with ISM, carefully read through the following pages.

You can call on 1800 954 559 or chat to us live via our website ndism.com.au if you have any questions.

ISM Product Procurement Service
Have you signed up for ISM's Product Procurement Service?*

YesNo
If you have not signed up for ISM's Product Procurement Service, please complete this form before submitting this request.

Participant Name*

First NameLast Name
NDIS Number*
Date of birth

DayMonthYear
Date
How do you want to receive the item?*

DeliveryClick and CollectOther
Phone Number For Order Updates*
Please enter a valid phone number.
Delivery Address*

Street Address

Street Address Line 2

CityState Province

Postal Code
Click and Collect Suburb (Store)*
Do you certify that you accept any delivery fees will be charged to your NDIS plan?*

I understand that any additional costs associated with the delivery of the requested product(s), which may not be included in the displayed item price, will be charged to my NDIS plan.
Are you purchasing multiple items today?*

YesNo
How many products are you requesting ISM to purchase today?*
Online Retailers Website Link/URL - 1*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
Description of Purchase/s*
How much do the item/s cost? - 1 *
Online Retailers Website Link/URL - 2*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
How much do the item/s cost? - 2*
Online Retailers Website Link/URL - 3*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
How much do the item/s cost? - 3*
Online Retailers Website Link/URL - 4*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
How much do the item/s cost? - 4*
Online Retailers Website Link/URL - 5*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
How much do the item/s cost? - 5*
Online Retailers Website Link/URL - 6*
Indicate the desired quantity after the URL. For Example: /back_scratcher x2
How much do the item/s cost? - 6*
How is this purchase disability related?*
Purchase Agreement*

I agree that I have authority to submit the above request; that the product is related to the Participant's disability; is goal-oriented; and is low risk, low cost.
Disclaimer Regarding Liability for Product Procurement

By submitting this procurement request, I acknowledge and agree to the following:
- Waiver of Liability: Independent Support Management (ISM) shall bear no liability for any claims, debts, or liabilities arising from the purchase of products on behalf of the Participant. By proceeding with this request, I fully waive any and all claims against ISM related to the procurement of these products.
- Responsibility of the Participant: I understand that it is the sole responsibility of the Participant (or their representative) to ensure that the requested products are "reasonable and necessary" supports in accordance with NDIS guidelines. ISM does not assume any responsibility for the appropriateness or compliance of these purchases.
- Due Diligence: ISM may provide assistance in procuring requested products; however, the ultimate responsibility for verifying that such products meet the Participant's needs and align with their NDIS plan rests with the Participant (or their representative).
- Replacement Support Process: If the requested product is intended as a replacement support, the Participant or their representative must ensure that all necessary justifications and documentation are provided for the NDIA’s approval. ISM will not be liable for any outcomes arising from the NDIA’s decisions regarding such requests.
- Legal Advice: This disclaimer is provided for informational purposes only. Participants are strongly encouraged to seek independent legal advice regarding their rights and obligations under the NDIS framework or by calling the NDIA on 1800 800 110.
By accepting these terms, I confirm that I have read, understood, and agree to the conditions outlined in this Disclaimer.I accept that this Request will not be actioned until the 6th of January 2025 at the earliest.
What is your relationship to the Participant?*

I am the ParticipantI am the NomineeI am their Support CoordinatorOther
Authorised Persons Name*

First NameLast Name
Signature*

Clear
Email Receipt*
Should be Empty:

Product Procurement Request Form