Example of an NDIS Service Agreement
The purpose of this agreement is to ensure you and your Provider have an agreed set of expectations as to how your services will be delivered.
Participant
Name
Date of Birth
NDIS Number
NDIS Plan Dates
Address
Participant’s Representative/Carer
Phone number
Support Coordinator or other useful contact (where relevant)
Name:
Phone:
Email:
How is the plan managed? (if plan-managed, please complete contact details)
Rights and Responsibilities
The Provider agrees to:
· actively work with the Participant to identify their wishes, will, preferences and rights to establish goals and needs and subsequently develop a Support Plan
· where appropriate, assist the participant to access an advocate as required by referral to appropriate services eg. Association for Children with a Disability or VALID.
· work with the Participant’s advocate, trusted decision maker and/or family member to assist the participant to exercise choice and control and to have their voice heard in matters that affect them.
· review the provision of supports at regular intervals with the Participant and their advocated or trusted decision maker
· provide the agreed safe and high-quality supports that meet the Participant’s needs at the Participant’s preferred, location and times whenever possible
· respect and respond to the cultural values and beliefs of the participant
· communicate openly and honestly in a timely manner and in a way the participant can best understand including using an interpreter if required
· treat the Participant with courtesy and respect
· inform the Participant of all costs associated with the provision of supports including the cost associated with cancellations
· protect the Participant’s privacy and confidential information as per the Privacy Act 1988
· store Participant information in a secure web-based system that is password protected
· use secure telehealth platforms
· inform the participant how to make a complaint and treat them fairly and impartially if they make a complaint
· listen to the Participant’s formal and informal feedback, resolve problems quickly and improve services or opportunities where possible
· give the Participant a minimum of 48 hours’ notice (where possible) if the Provider has to change a scheduled appointment to provide supports
· provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act and Rules, and the Australian Consumer Law
· keep accurate records on the supports provided to the Participant
· issue regular invoices for the provision of supports delivered to the Participant
· give the Participant the required notice if the Provider needs to end the Service Agreement
· continually inform the Participant of possible risks and benefits associated with achieving their goals
· investigate any incidents that occur and follow NDIS (Incident Management and Reportable Incidents) Rules 2018. This includes involving the Participant in the investigation and determining actions / outcomes.
· provide Risk Management, Incident Management and Complaints Management Policies and Procedures as requested.
The Participant / Participant’s representative agrees to:
· be involved in the development of your Support Plan, informing the Provider how you wish your Services/ Supports to be delivered
· provide accurate information regarding the Participant’s support needs and goals
· keep your Provider informed of changes to your personal information
· inform your Provider if you are receiving other services or supports
· use equipment safely – in the manner in which you have practiced with your Provider
· ensure there are appropriate funds available for claiming services that have been booked and provided. If your Provider is unable to make a claim to NDIA for the provision of a service due to insufficient funds you are responsible for payment
· treat the Provider with courtesy, respect and dignity
· provide a safe and smoke-free environment for the Provider to work in if seen in the community
· talk to the Provider if you have any concerns about the supports being provided
for Occupational Therapy appointments, reply “YES” to your reminder SMS so we know to prepare the session. If you are unable to attend your appointment, reply “NO” or “Cancel” to the SMS message so it is received in our system.
· let the Provider know immediately if you need to end the Service Agreement or your NDIS plan is suspended or replaced by a new NDIS plan or you stop being a Participant in the NDIS
· give the Provider feedback or lodge a complaint if you are dissatisfied with the service or the way it is delivered (See Complaint Policy below)
· discuss your concerns with possible risks associated with achieving your Support Plan
· participate in feedback and survey opportunities
· request a copy of any of our Policies and Procedures if further information is required.
Support Plan & Costs
The NDIS goals will be recorded on the participant’s progress notes. Relevant short-term goals will be identified with the participant and their family and monitored using progress notes. The following table describes the description of services and the cost to meet those goals. Each year as part of the NDIS Review, a report will be written which identifies the outcomes of the goals and makes recommendations for the following year.
Description of Services & Item Number: Therapeutic Support (OT) 15_056_0128_1_3
Where Online
Number of Sessions 10
Duration 10 hours
Cost $1939.90
The above table is used to list the number of individual or group Occupational Therapy sessions.
The cost of our services are in line with the NDIS Price Schedule 2019-2020 and the NDIS Support Catalogue 2019-2020.
The main reason that the Participant is accessing this Program/Provider is:
The relevant NDIS goals are (or provide a copy of the NDIS plan):
________________________________________________________________________________
Risks/Concerns/Allergies/Medical Conditions are:
Making a Complaint or Giving Feedback
If the Participant wishes to give the Provider feedback or wishes to make a complaint, the Participant, their advocate or trusted decision maker can:
· Discuss your issue / complaint with staff
· Contact the Director, Lee Frances on 0448028933 or email lee@creativelc.com.au
· Contact the NDIS Quality and Safeguards Commission
o via phone 1800 035 544
o by filling the online complaint form on the NDIS website
For further information on making a complaint, ask to see our Feedback and Complaints Management Policy or look at the NDIS Commission’s Fact Sheet on How to Make a Complaint
CONSENTS AND AGREEMENT
Please delete ticks for statements where you do not agree:
I understand and agree to the terms and conditions of this Service Agreement ending on ___________ (insert end date of Service Agreement)
I give my consent to commence the Services outlined in my Support Plan
I consent to my Provider sharing and obtaining pertinent information with my other Service Providers and pertinent others with the exclusion of ____________________________________________ (enter name if applicable)
I consent to my Provider taking photographs and video for use within the context of the provision of services
I consent to my Provider taking photographs or video for promotional purposes eg. for use on Facebook or the website – I understand that I will be able to approve it prior to it being used
I consent to participate in a participant satisfaction survey and I understand I may be contacted by a third party to complete a questionnaire
I consent to participating in an NDIS quality management activity (ie. Audit) which may include being contacted by a third party auditor
I consent to participate in video-conferencing using Zoom and will endeavour to do so safely
By typing your name or signing this Agreement, you agree to all of the information included.
Participant/Representative’s Signature:
Date:
Service provider’s name / Signature:
Lee Frances
The electronic signatures of the parties, typed or electronic symbol, included in this Service Agreement are intended to authenticate this agreement and to have the effect as manual signatures.