Please complete the following form to provide us with the information and consent we need to get the equipment or services to you or your client as soon as possible.

Who can complete this form?

PURCHASE

• Low-cost, low-risk items (under $1,500, Level 1 Assistive Technology): The participant or their authorised representative can usually complete this form directly.
• Higher-cost or higher-risk items (Level 2 and above, including complex equipment, assistive technology, or home modifications): This form should be completed by a qualified allied health professional, such as an Occupational Therapist.
• Support coordinators may assist with completing the form but cannot replace the required professional assessment where the NDIS specifies one.
   

HIRE / RENTAL

• Low-cost or standard items (e.g., walking frames, basic wheelchairs, pressure cushions): An allied health professional is usually not required if funding is already included in the participant’s plan.
• High-cost or specialised hire items (e.g., complex beds, mattresses, or hoists): Completion of this form must be done by an allied health professional (typically an OT) to provide clinical justification that the equipment meets the participant’s needs.
   

SERVICE / REPAIRS

• Routine servicing or repairs: An OT report or professional approval is not usually required if the item is already funded in the participant’s plan. The participant or their authorised representative can complete this form directly.
• Upgrades or modifications to meet new needs: An OT report may be required to justify the change. In these cases, the form should be completed by the allied health professional or support coordinator (in consultation with allied health professional).

NDIS Support Item Codes

Please select all applicable NDIS Support Item Codes for the equipment or service requested.

Important: You must not guess these codes. The codes you select here will determine where funds are drawn from in the participant’s NDIS plan.

Each item in the quote must have a corresponding code so please select all that apply. If you are unsure, consult the participant’s plan or a qualified professional.

I consent to Alpha Lifecare collecting and using my NDIS information for the purpose of providing supports and services.

Disclaimer

By providing this consent, I confirm that:

• All details I have provided are true and correct
• For purchases or services: There are sufficient funds available in my NDIS plan to cover the cost of the sale
• For Hire: There are sufficient funds available in the NDIS Plan to cover ongoing hire charges from the date of delivery until the date of collection
• Alpha Lifecare will use the information in this form to claim the required funds to provide the requested
• Alpha Lifecare will be promptly notified of any changes to the details provided, including but not limited to participant information, funding availability, or plan manager details

The National Disability Insurance Scheme (NDIS) is run by the National Disability Insurance Agency (NDIA). The NDIS is one component of the National Disability Strategy, which brings together community, government, and industry to address the challenges faced by people with disability. It ensures they are supported by mainstream services such as health, education, and transport, as well as the wider community.

The aim of the NDIS is simple: to provide Australians who are born with, or acquire, a permanent and significant disability with the reasonable and necessary supports they need to live an ordinary life. The vision of the NDIS is also simple: to build independence and increase opportunities and social participation for people living with disability in Australia.

The NDIS consists of two parts: NDIS-funded supports for eligible participants, and Information, Linkages and Capacity Building (ILC), which is focused on connecting people with their communities. Eligible participants receive funded supports, and each NDIS participant has a plan that focuses on building independence and increasing opportunities. This could include participating in community activities, getting a job, or learning new skills.

The important thing is that participants have choice and control over the supports they need to live the life they want. By 2020, around 460,000 people with disability living in Australia were expected to have a funded plan under the NDIS. ILC, on the other hand, is available to all people with disability, whether they are NDIS participants or not.

For more information, visit the NDIS website: https://www.ndis.gov.au

Is Alpha Lifecare an NDIS provider?
Yes. Alpha Lifecare is a registered NDIS provider.
Provider No: 4050087969

Who is eligible for NDIS?
You may be eligible if you:
• Are under 65 years old
• Are an Australian citizen, permanent resident, or permanent visa holder
• Meet disability or early intervention requirements

Check your eligibility here

NDIS Participants Page

You can contact the NDIS for further information on 1800 800 110.

What if I'm 65 or older?
You may not be eligible for the NDIS, but support is available through My Aged Care.

How do I claim through my NDIS plan?
Visit the NDIS Participants page or call 1800 800 110 for assistance.

Are repairs and maintenance covered?
Repairs and maintenance for equipment can usually be funded through your NDIS budget.