NDIA Information Consent Form

NDIA Information Consent Form
By complting and signing this form you give the National Disability Insurance Agency (NDIA) permission to share your information on your behalf. The information we will share will depend on the permission you give us on this form.
Part A: Participant details

If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please complete this section about the participant you are representing.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
NDIS Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Part B: Child representative, plan nominee, legally appointed decision maker details
if you are completing this form on behalf of a participant:
- Under 18 years for whom you have parental responsibility, or a child representative
- For whom you are a plan nominee
- For whom you are a legally appointed decision maker (for example, a guardian).
The NDIA may ask you to provide confirmation that you are authorised to represent the participant and to verify your identity.
Please indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision maker
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Part C: Third party details and consent
Consent:

I consent to the NDIA giving information about me (or the participant I am representing who is identified in Part A of this form), to the following people and/or organisations.
Name

First NameLast Name
Organisation Name
Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation
My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service providers
My NDIS information

The assessments and reports held about me by theNDIAMy NDIA Access Request FormA copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals andAspirationsA copy of my current NDIS Plan’s funding andsupportMy NDIS ContactA copy of all parts of my previous NDIS Plan/sA copy of my previous NDIS Plan/s Goals andAspirationsA copy of my previous NDIS Plan/s funding andsupport
Any other information - If so, please specify what this information is below:
Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

My NDIS Access requestTo prepare my first NDIS planTo review my NDIS planTo implement my NDIS planTo review a decision made by the NDIATo discuss an enquiry, complaint or feedbackTo discuss a provider payment queryTo discuss a provider quoteTo discuss an Administrative Appeals TribunalrequestTo discuss compensation I am or will be receivingOther. Please specify below:
Other
Please mark the relevant box below to indicate the length of time you are providing the consent forOngoing For the duration of my current NDIS plan For a set time ending Date Once only
Person and/or Organisation 2

First NameLast Name
Organisation
Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation
My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service providers
My NDIS information

The assessments and reports held about me by the NDIAMy NDIA Access Request FormA copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals and AspirationsA copy of my current NDIS Plan’s funding and supportMy NDIS ContactA copy of all parts of my previous NDIS Plan/sA copy of my previous NDIS Plan/s Goals and AspirationsA copy of my previous NDIS Plan/s funding and support
Any other information - If so, please specify what this information is below:
Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

My NDIS Access requestTo prepare my first NDIS planTo review my NDIS planTo implement my NDIS planTo review a decision made by the NDIATo discuss an enquiry, complaint or feedbackTo discuss a provider payment queryTo discuss a provider quoteTo discuss an Administrative Appeals Tribunal requestTo discuss compensation I am or will be receiving
Other - Please specify below:
Please mark the relevant box below to indicate the length of time you are providing the consent forOngoing For the duration of my current NDIS plan For a set time endingDate Once only
Person and/or organisation 3

First NameLast Name
Organisation
Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation
My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supports
My NDIS information

The assessments and reports held about me by the NDIAMy NDIA Access Request FormA copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals and AspirationsA copy of my current NDIS Plan’s funding and supportMy NDIS ContactA copy of all parts of my previous NDIS Plan/sA copy of my previous NDIS Plan/s Goals and AspirationsA copy of my previous NDIS Plan/s funding and support
Any other information - If so, please specify what this information is below:
Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

My NDIS Access requestTo prepare my first NDIS planTo review my NDIS planTo implement my NDIS planTo review a decision made by the NDIATo discuss an enquiry, complaint or feedbackTo discuss a provider payment queryTo discuss a provider quoteTo discuss an Administrative Appeals Tribunal requestTo discuss compensation I am or will be receiving
Other - Please specify below:
Please mark the relevant box below to indicate the length of time you are providing the consent forOngoing For the duration of my current NDIS plan For a set time endingDate Once only
Part D: Your declaration
Please note: NDIS participants’ aged 18 and over have other options instead of signing this consent form.
- If you are unable to sign in Part D, you may provide verbal consent to the NDIA.
- You can direct someone aged 18 and over to sign (your ‘delegate’) in the presence of a witness.
If you direct a delegate to sign on your behalf, your delegate and witness needs to complete Part E. Otherwise, please sign, below.
By signing this consent form (please markeach box below):

I understand I can obtain further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. You can find this information on the NDIS website(ndis.gov.au/privacy).I understand I have given the NDIA consent to give information about me to the third party or parties I have listed at Part C on this form so they can take the identified action/s on my behalf.I understand I can withdraw or change my consent toshare information and/or my permission for a third party to act on my behalf atany time.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
If you are not the participant, please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision maker (please provide theNDIA with details of this appointment if not already provided).
Part E: Your delegate’s declaration
Please note: This section is only to be completed if you, the participant, is unable to sign this form in Part D. Instead, your chosen ’delegate’ must be aged 18 and over and can sign in the presence of a witness.
Witness certification (please mark each box below):

I certify this document was signed by the delegate in the presence ofthe person providing consentI certify that consent was provided freely and voluntarilyI certify that the person providing consent has decision making capacity in relation to the provision of consent provided.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Privacy and your personal information
Collection of your personal information

The National Disability Insurance Agency (NDIA) would like some personal information from you to simplify your engagement with the NDIS. Any personal information you provide to the NDIA is safe under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. You can also ask to see what personal information (if any) we hold about you at any time and can seek correction if the information is wrong.

Personal information use and disclosure

The NDIA will use your information to support your involvement in the NDIS.

The NDIA will NOT use any of your personal information for any other purpose, or disclose your personal information to any other organisations or individuals (including any overseas recipients), unless authorised by law or you provide your consent for us to do so.

The NDIA’s privacy policy describes
- How we use your personal information.
- Why some personal information may be given to other organisations from time to time.
- How you can access the personal information we have about you on our system.
- How you can complain about a privacy breach, and how the NDIA deals with the complaint.
- How you can get your personal information corrected if it is wrong.
You can find the policy at the NDIS website (ndis.gov.au/privacy).

Personal information storage

The NDIA uses an Australian Government computer system to store personal information. System users, other than NDIA staff, may at times be able to see your name when they perform program duties, however they can’t record, use or disclose information, and they will not know if you become an NDIS participant. State or territory government officials may also have personal information access as part of the agreement between governments to assist the states and territories in their NDIS evaluation.
Should be Empty:

NDIA Information Consent Form

Part A: Participant details

Part B: Child representative, plan nominee, legally appointed decision maker details

Part C: Third party details and consent

Part D: Your declaration

Part E: Your delegate’s declaration

Privacy and your personal information