ABN: 33 648 888 608

NDIS Service Agreement

NDIS Service Agreement

A Service Agreement can be made between a Client or their Authorised Representative (e.g. a parent, guardian or other nominated person) and a Provider.

In this Service Agreement, the term "Party" or "Parties" refers to Jump Start Therapy Services and the Client/Client's Authorised Representative who is making this Agreement.

Client Details

This Service Agreement is for (type Client's Name):

Client First Name *

Client Last Name *

The Person that is Authorised to sign this Service Agreement is:

The Client? *

The Authorised Representative? *

Client's Authorised Representative *

This Service Agreement is between the Client/Authorised Representative and

Please check this box if a Hardcopy is required of this Service Agreement

The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Client's National Disability Insurance Scheme Plan.

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.

Contact Details

Client First Name

Client Last Name

Client Date Of Birth *

NDIS Number *

Phone

Email

Address *

Client Representative Name

Client Representative Phone *

Client Representative Email *

Client Representative Address

Relationship to Client

Schedule of Supports

Services requested in this Service Agreement *

Occupational Therapy

Send Service Agreement to the Referrer

Service Start Date *These are the dates in which Jump Start Therapy Services will be providing supports

Service End Date *

Update on Current Service Agreement for this Plan Period

Previously Agreed Occupational Therapy Hours/Dollars

Previously Agreed Nursing Hours/Dollars

Please prepare my funding in

Occupational Therapy DollarsAdditional $ Required

Occupational Therapy HoursAdditional Hours Required

Please note that amount "Previously Agreed Hours/Dollars" box is a reflection of previously AGREED to hours and the "Total" figures below incorporates the further funding requested.

This is the maximum hours requested. We will not bill for time that we do not use.

Occupational Therapy Budget TotalThis is the grand total of the service agreement

Occupational Therapy Hours TotalThis is the grand total of the service agreement

Clinician

Alison (Occupational Therapist) Ph: 0410 309 638Linda (Occupational Therapist) Ph: 0428 300 178

Clinicians Email

alison@jsts.com.aulinda@jsts.com.au

Type of Support:

Occupational Therapy

Capacity Building: Improved Daily Living; Therapeutic Supports; Early Childhood Supports

Core: Therapy Supports and Early Childhood Supports - Disabilty Related Health Supports

Description of Support:

For Occupational Therapy, the service delivery details (including frequency and duration of services) are to be negoatiated with the Client/Client's Authorised Representative.

Price and Payment Information:

- The hourly rate is in accordance with the conditions stated in the NDIS Pricing Arrangement and Price Limits and Jump Start Therapy Services Information about Fees and Services. The hourly rate, travel rates and guidelines for services (including cancellation policy) will be subject to change, in accordance to changes to the NDIS Pricing Arrangement and Price Limits, or at Jump Start Therapy Services discretion.

- Click here to review information regarding our Fees and Services. Signing this Service Agreement indicates your consent to these Fees and Services.

Funding

Jump Start Therapy Services will seek payment for their provision of supports after the supports have been delivered in accordance with the clients plan funding type noted below:

SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Jump Start Therapy Services will send the client / client representative a Tax Invoice for those supports for the client / client representative to pay. The client / client representative will pay as per the Terms stated on the Tax Invoice.PLAN MANAGED - The client has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Jump Start Therapy Services will claim payment for those supports from:

Email for billing

Plan Manager *

Plan Manager Phone *

Plan Manager Email *

Plan Manager Address

Payments

Jump Start Therapy Services will seek payment for their provision of supports after supports have been provided.

For NDIS plans that are self managed, managed by the Client's Nominee or Plan Managed by a Registered Plan Management Provider, Jump Start Therapy Services will send a Tax Invoice to the nominated person or organisation.

How and when to pay is stated on the Tax Invoice. Please check that the nominated person or organisation can meet these terms. We may put services on hold if these terms and conditions aren't met.

Copy of Client's NDIS Plan

It is helpful for the Clinician to have a copy of the My Profile and Goals sections of the NDIS Plan. This ensures we are working towards your stated goals. It also helps when applying for funding and completing reports for the NDIS when needed. It is helpful to include the Funding Sections of your Plan, especially if you need to apply for Assistive Technology; Home Modifications or Home and Living Supports.

It is your choice whether or not to provide a copy of all or parts of the NDIS Plan.

NDIS Plan for the current period

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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 two weeks notice.

If either Party seriously breaches this Service Agreement the requirement of notice will be waived.

Signatures

Are all details correct?

Yes - proceed to signing Service AgreementNo - please review and update

Notes:

I consent for my Signed Service Agreement to be provided to:

my Plan Manager (if appropriate)my Support Coordinator

Plan Manager Email

Support Coordinator Name *

Support Coordinator Email *

By signing this Agreement, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Agreement and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this Agreement.

I have read & understood this Service Agreement and understand each item listed within. I understand Jump Start Therapy Services will be engaged to provide services that it is entitled to receive payment in return.

I have read and agree to the Fees and Services *

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Agreement as the Client's Authorised Representative.

Signature *

Draw signature|Type signatureClear

Authorised representative

Date

Signed on behalf of:

Client

Date

Thank you - we will review your response promptly and return an updated form for you to approve. Please hit "Submit" button below to proceed.

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