Service Agreement SDA 20

NDIS Service Agreement

This Service Agreement is for a participant in the National Disability Insurance Scheme (participant), and Advance Rehab Centre PTY LTD.

This Service Agreement is made for the purpose of providing supports under the clients NDIS plan and is designed to ensure there is a shared understanding of expectations of what supports will be delivered, how they will be delivered, and each party’s responsibilities and obligations and how to resolve any problems that may arise.

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 client 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.

Changes to this Service Agreement

If changes to the supports 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 in writing, signed and dated by the parties.

Ending this Service Agreement

Should either party wish to end this Service Agreement they must give 2 weeks notice. If either party seriously breaches this Service Agreement the requirement of notice will be waived.

Participant details

Participant First Name *

Participant Surname Name *

Participant Date Of Birth *

Participant Representative Name (Optional)

Address

Phone *

Email address of participant or representative *

NDIS Number *

Existing Plan Start Date *

Existing Plan Expiry Date *

Gender

MaleFemaleNon-binary or gender-diverseOther

Pronouns

He/him/hisShe/her/hersThey/them/theirsOther

Are Telehealth services required for supports outside of Sydney? *

YesNoUnsure

Preferred method of communication for appointments

PhoneEmail SMSOther

English is a second language

Yes - interpreter requiredYes - no interpreter requiredNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

Next of Kin Contact Details

Next of kin - name

Next of kin - email

Next of kin - phone

Guardian Contact Details

Guardian Name

Guardian email

Guardian phone

Support Coordination Details

Support Coordinator Name

Support Coordination Organisation

Support Coordinator email

Support Coordinator phone

Housing goals

Diagnosis funded by the NDIS

What Are Your Housing Goals?

Existing Accommodation Situation

Please provide additional information including timescale for required housing report, type of assessment and report required if known.

Please highlight any known risks that therapists need to be aware of including behaviours - physical or environmental. Please state what measures are in place to manage these risks.

Advance Rehab Centre PTY LTD Responsibilities

We will:

(a) provide agreed Supports that meets your needs and are conducted in a safe environment;

(b) work with you to provide the Supports at your preferred times;

(c) review your needs regularly to ensure the Supports continue to be suitable;

(d) communicate in an honest and timely manner with you;

(e) consult you on all decisions about how Supports are provided to you;

(f) engage in clinical collaboration when required to establish treatment direction in complex situations

(g) listen to your feedback and resolve any problems as soon as possible;

(h) deal with your personal information in accordance with our Privacy Policy;

(i) provide the Supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 (Cth); and

(j) maintain accurate records of the Supports we have provided to you and provide high quality reports to support your needs

(k) other than when a therapist is unexpectedly unwell, give you a minimum of 24 hours’ notice if the Provider has to change a scheduled appointment to provide supports.

Participant Responsibilities

By signing this agreement you (or your representative) agree to:

(a) inform the Provider about how you wish the supports to be delivered to meet your needs

(b) treat the Provider with courtesy and respect the rights and safety of our employees and contractors, including ensuring the workspace/home is tidy, smoke-free, free from hazards and by controlling or restraining pets. Abusive or inappropriate behaviour towards our staff is not tolerated and may result in the cancellation of your appointments.

(c) communicate with us in an open, honest, and timely manner, including notifying us of any changes to your personal circumstances which may impact the way that we provide the Supports to you;

(d) talk to the Provider if you have any concerns about the supports being provided

(e) give the Provider the required notice if you determine to end the Service Agreement (See ‘Termination’ above for more information), and

(f) immediately notify us if the NDIS Plan is replaced by a new plan or you stop being a participant in the NDIS;

(g) monitor spending against your NDIS Budget to ensure there are sufficient funds to pay for the agreed Supports provided; and

(h) pay the Support Fee where your NDIS Budget does not cover all or part of the Support Fee.

Payments

Advance Rehab Centre PTY LTD seek payment for their provision of supports after the supports have been delivered.

SELF MANAGED - If you are self-managed: we will provide you with an invoice for the Supports to be paid within 24 hours of receiving the invoice. You are solely responsible for making a Payment Request to receive the funds under your NDIS Plan/NDIS Budget; and we reserve the right to reduce the Supports or stop providing the Supports to you if payment is not in accordance with this Agreement and we may refer you to a collection agency if funds are not paid.NDIA MANAGED - If your funds are NDIA-managed we will create a Service Booking in the NDIS Portal in accordance with this agreement, then make subsequent payment requests after providing Supports. We reserve the right to reduce the Supports or stop providing the Supports to you if payment is not in accordance with this Agreement and we may refer you to a collection agency if funds are not paid. PLAN MANAGED - If your funds are plan-managed we will request your Plan Manager reserve funds in accordance with this agreement. We will send invoices to your Plan Manager for payment following each Support and we reserve the right to reduce the Supports or stop providing the Supports to you if payment is not in accordance with this Agreement and we may refer you to a collection agency if funds are not paid.

Plan Manager Name

Plan Manager Organisation

Plan Manager Email Address

Plan manager phone

Feedback, complaints and disputes

If the participant wishes to give Advance Rehab Centre PTY LTD feedback or is not happy with the provision of supports and wishes to make a complaint, the participant can contact the Allied Health Manager 0n 9906 7777 or email lexie@archealth.com.au

If the client is not satisfied or does not want to talk to this person, at any time, they can make a complaint to the NDIS Commission. Complaints to the NDIS Commission can be lodged:

online at www.ndiscommission.gov.au; or
by phone on: 1800 035 544.

Privacy

Upon submitting the form, your personal details will be sent securely to Advance Rehab Centre PTY LTD. Submission of this form assumes that you have read and accept the privacy policy available by clicking the link.

I authorise my therapist to liaise with my GP, support networks, other health professionals and housing agencies with regards to progressing towards my housing goals.

Schedule of Supports

Based on the information and goals you have provided us, we have determined that the Supports are reasonable, necessary and comprehensive for your specific needs.

(a) If any of the information you have provided us is incorrect or incomplete, please let us know as soon as possible. Failure to provide us with the most accurate and up to date information may result in us recommending Supports which are not suitable for your individual needs.

(b) If changes to the supports 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 in writing, signed and dated by the Parties.

(c) The supports and their prices are set out in the Schedule of Supports on the NDIS website and the rates for therapy supports are set by the NDIS. These prices are reviewed and adjusted on 1st July each year and any price adjustment by the NDIS will be passed onto the participant immediately. All prices are GST inclusive (if applicable) and include the cost of providing the supports.

(d) If an Advance Rehab Centre therapist is travelling to see you, as per NDIS provider travel fees (labour cost), there will be an additional cost which is calculated at the same hourly rate as the support received. This amount will be calculated and discussed with the participant or referrer prior to the first appointment.

(e) Rarely, an additional 'non-labour provider travel cost' may be incurred on occasions of significant parking charges or services requesting delivery beyond the Greater Sydney area. Any additional non-labour costs will be discussed and agreed prior to service delivery taking place.

(f) Additional expenses (i.e. things that are not included as part of a Participant’s NDIS supports) are the responsibility of the participant and are not included in the cost of the supports. Examples include entrance fees, event tickets, meals, excessive parking charges, etc.

(g) Where you require a Housing Eligibility Report, we require 10 weeks to prepare the report

(h) The Support Fees set out above are the amounts payable to us before your NDIS Budget is applied. You will be required to pay all or part of the Support Fee if your NDIS Budget does not cover all or part of the Supports.

(i) We do not manage your NDIS Budget. We recommend that you confirm how much of the Support Fee your NDIS Budget will cover before receiving the Supports. The Support Fee is inclusive of GST (if applicable).

(j) We invoice and require payment paid in full for each consultation and billed item within our payment terms.

(k) If a report is to be provided, payment of any and all outstanding amounts must be made in full BEFORE final copies of the report will be released.

Funding

In order to help you best achieve your goals and plan your supports efficiently, we require a minimum of 15 hours to commence services. In addition to a thorough housing solutions and functional capacity assessment, complex reports may also require co-consultation within the team to ensure a sound and comprehensive position can be reflected in your report that includes consideration of legislation and precedence.

I confirm that I have 20 hours available in my plan to commence this service agreement. *

YesNo

Price & Payment Information

Therapy and travel will be charged at the maximum NDIS rate per hour for occupational therapy services and is subject to any price changes made by the NDIS. The rate is currently gazetted as $193.99 per hour.

Provider Services may include:

Assessment and background reading of information provided
Clinical admin including phone calls/communication with other health professionals and third parties
Attendance at team meetings/case conferences
Assessment, sourcing and trial of equipment as required
Reports, forms or letters as required by the NDIS or requested by the participant

Cancellation Policy

At Advance Rehab Centre PTY LTD we value consistent and high quality intervention.

A cancellation occurs when you do not show for an arranged appointment, or when you provide less than 48 hours' notice (2 clear business days) to cancel the service . Advance Rehab Centre reserve the right to claim the full fee of the service under the NDIS 'short notice cancellations' conditions.

(a) Cancellations with notice less than 48 hours will incur the full consultation fee.

(b) Failure to attend an appointment with notice less than 48 hours will incur the full consultation fee.

(c) Where possible, your allocated therapy time will be used by your therapist to deliver any telehealth (where appropriate) or non-face to face clinical services outlined in the participants treatment plan.

I have read and understand the cancellation policy *

Stage of enquiry

I would like

To book a Housing team assessment To book a phone consult with a housing team OT Someone from the housing team to contact me

13 . Agreement signatures

The parties understand and agree to the terms and conditions of this Service Agreement.

Signature of Participant/ Representative *

Clear

Name of Participant/Representative *

Signed Date *

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