Service Agreement

Chosen Family Service Agreement

ABN: 40 660 703 122, Chosen Family is a Registered Provider. Registration number: 405 014 6042
NOTE: A Service Agreement can be made between a Participant and a Provider or a Participant’s representative and a Provider. A Participant’s representative is someone close to the Participant, such as a family member or friend or someone who manages the funding for supports under a Participant’s NDIS plan.
This Service Agreement is For
Participant Name*

First NameLast Name
Participant Date of Birth*

DayMonthYear
Date
NDIS Number
Email*
example@example.com
NDIS Plan Dates
Start Date*

DayMonthYear
Date
Expiry Date*

DayMonthYear
Date
a participant in the National Disability Insurance Scheme and is made by and between:
Participant / Participant’s representative*
AND

The Provider
This Service Agreement will commence on*

DayMonthYear
Date
and remains in please until either party requests that the Service Agreement be ended.

The NDIS and this Service Agreement

This Service Agreement, appendices, is made for the purpose of providing supports under the Participant’s National Disability Insurance Scheme (NDIS) plan. A copy of the Participant’s NDIS plan is attached to this Service Agreement. 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 supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and includes the cost of providing the supports. Provision of Supports will be charged at the current unit price as set by the NDIA. Please note that whenever prices are increased or a new NDIS Price Guide is released, any increased NDIA Unit Prices or changed NDIS Terms & Conditions will be applied automatically by Chosen Family and for the life of this Agreement.

The [Participant / Participant’s representative] agrees that this Agreement applies to the following Services/Supports provided by the Provider. This Agreement does not affect any other Agreement made between the [Participant / Participant’s representative] and the Provider for the provision of any other Services/Supports.
Please select type of services:*

Community AccessRespiteHousehold tasks (Cleaning, Laundry, De-cluttering, Meal Preparation, Watering Plants, Shopping and errands)Personal Care (Showering, Bathing, Grooming, Toilet & Continence SupportAccommodationLGBTQIA+ TrainingOther
Plan is*

Self-managedPlan ManagedNDIA Managed
Responsibilities of Provider
- Review the provision of supports at least every 3 months with the Participant. Feel free to contact us via call (02) 4713 1801, Text Us! 0482 077 797 or email : info@chosen.family
- Chosen Family is a Registered Provider. Registration number: 405 014 6042
- Once agreed, [provide / coordinate / fund] supports 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 and what supports are provided
- Give the Participant information about managing any complaints or disagreements and details of the provider’s cancellation policy (if relevant)
- Listen to the Participant’s feedback and resolve problems quickly
- Give the Participant a minimum of 24 hours’ notice if the Provider has to change a scheduled appointment to provide supports
- 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 supports 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, and
- Issue regular statements of the services provided to the Participant.
Responsibilities of [Participant / Participant’s representative]
Participant's Email*
example@example.com
The [Participant / Participant’s representative] agrees to:
- Inform the Provider about how they wish the supports 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 complaints or concerns about the supports being provided
- Give the Provider a minimum of 48 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
- If the Participant commits an offence and are reprimanded into custody, the Provider can claim the seven (7) days cancellation fee for all supports rostered for the following week
- Consent to the requirements of the Provider’s Policies and Procedures, and the terms of this Agreement
- Give the Provider the required notice if the Participant needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information), and
- 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.
- The [Participant / Participant’s representative] 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.
Payments

The Provider will seek payment for the provision of supports after the supports have been delivered.
[If the funding for any of the supports provided under this Service Agreement is managed by a Registered Plan Management Provider:] The Participant has nominated the Plan Management Provider will manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the Provider will claim payment if those supports from. Additional expenses (for example, things that are not included as part of a Participant’s NDSI supports) are the responsibility of the participant or their plan nominee to pay directly to Chosen Family. These are not included in the hourly rate for support set by the NDIA. Examples include service provider travel and transport fees, public transport costs, community venue activity entrance fees, event tickets, meals, etc.
Changes to this Service Agreement

If changes to the supports/Services, 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 evidenced in writing.

Ending this Service Agreement

Should either Party wish to end this Service Agreement they must give 28 days notice. 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, or is not happy with the provision of supports and wishes to make a complaint, the Participant can contact the Chosen Family Safeguarding Officer, by emailing Info@chosen.family or completing our complaints and feedback form on our website. Alternatively contact our office team on Calls- (02) 4713 1801 or Text Us! 0482 077 797 .

If the Participant is not satisfied with the response, 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.

Policies, Procedures & Manuals

The Provider has a suite of policies, procedures and anuals that govern the delivery of Services to the Participant. These include a variety of roles and responsibiltiies that the Provider requires of the Participant so Services can be delivered safely and effectively.

The [Participant / Participant’s representative] agrees to adibe by the policies, procedures and manuals, and acknowledges that the Provider delivers Services in accordance with them.

Reporting

At times, the NDIS and/or NDIA Commission may request the Provider to submit evidence that Supports/Services have been provided to the Participant as required under the NDIS Act.

The [Participant / Participant’s representative] consents to the Provider maintaining these records and providing such evidence if requested.
Contact Details

The Participant / the Participant’s representative] can be contacted on:
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suburb*
State or Territory*

NSWQLDVICACTWASA
Alternative Emergency Contact Person
Alternative Contact Name

First NameLast Name
Alternative Phone Number
Please enter a valid phone number.
The Provider can be contacted on:

Name: Chosen Family Australia

Mobile: Call (02) 4713 1801

Text Us! 0482 077 797

Email: info@chosen.family

Address: PO Box 7116, Penrith South NSW 2750

Acceptance

By signing this Service Agreement, the [Participant / the Participant’s representative] agrees that they have read and understood the terms and conditions within, and wish to accept the Supports/Services provided by the Provider.

Execution of Agreement

Executed as an Agreement for valuable consideration. Signed under the Electronic Transactions Act 2000
Participant / Participant's Representative Name:*

First NameLast Name
Date Signed*

DayMonthYear
Date
Relationship to Participant
Provider: Chosen Family

Name: Chosen Family Australia

Mobile: Call (02) 4713 1801

Text Us! 0482 077 797
Date Signed*

DayMonthYear
Date
Should be Empty:

Chosen Family Service Agreement

This Service Agreement is For

NDIS Plan Dates

Responsibilities of [Participant / Participant’s representative]

Payments

Contact Details

Alternative Emergency Contact Person