ABN: 33 648 888 608

Private Service Agreement

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:

Client First Name *

Client Last Name *

The person that is authorised to sign this Service Agreement is:

For My Aged Care clients who have their funds managed, the Authorised Representative is the Service Provider who manages your package. For other clients, it is the person/organisation who will be responsible for paying for the Services.

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

Contact Details

Client's First Name

Client's Last Name

Client's Date Of Birth *

Client's Claim Number

Client's Phone Number

Client's Email

Client's Address *

Client's Representative Name

Client's Representative Phone Number *

Client's Representative Email *

Client's 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 services.

Service End Date *For My Aged Care Clients, this may be 12 months from the Start Date; for Medicare clients, this is the end of the calendar year.

Update on Current Service Agreement for this Plan Period

Original Funding Amount for Occupational TherapyIf new plan, enter 0. Use numbers with decimal points. Don't use $ sign in front.

Addition or reduction of funding *This is the amount you wish to add to the Service Agreement. Please use the prefix of + or - as appropriate. Use numbers with decimal points. Don't use $ sign in front.

Please note that amount "Original Funding Amount" box is a reflection of PREVIOUSLY AGREED to funding (if applicable) and the "Total" figures below incorporates the further funding requested.

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

Occupational Therapy Budget Total

Funding Amount for Occupational Therapy

Clinician

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

Clinician's email

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

Description of Services

The service delivery details (including frequency and duration of services) are to be negotiated with the Client/Client's Authorised Representative.

Price and Payment Information:

- The hourly rate is in accordance with the conditions stated in 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 at Jump Start Therapy Services discretion.

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

Funding

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

Please select from the options below regarding who to send the Invoice to:

Private/Medicare/Private Health Insurance - After providing services, Jump Start Therapy will send the client/client representative a Tax Invoice for payment. The client/client representative will pay as per the terms stated on the Tax Invoice.Other organisation - The client has nominated another organisation to fund services under this Service Agreement. After providing services, Jump Start Therapy Services will claim payment from:

Name of person/organisation paying *

Phone of person/organisation *

Email of person/organisation paying *

Address of person/organisation

Jump Start Therapy Services will seek payment for their provision of services after services have been provided. A Tax Invoice will be sent to the nominated person or organisation.

Payments

In addition to the invoice being sent to the person/organisation paying, I want a copy of the invoice sent to:

Client Email

Care Manager/Coordinator Email

Authorised Representative Email

Other Email - Please specify

For clients using Medicare or Private Health Insurance, you will be required to pay the account in full and then submit the receipt to Medicare or the Private Health Insurer to claim any eligible rebate.

How and when to pay is stated on the Tax Invoice. Credit card payment facilities are available upon request. 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 Referral

With the client/client representative's consent, please provide a copy of the referral (e.g. Chronic Disease Management Plan or Helping Children With Autism Plan / Complex Neurodevelopmental Disorders and Eligible Disabilities or Better Start); the client's medical summary (if relevant) from your doctor and/or relevant allied health or other reports.

Referral

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Referring Doctor Name *

Provider number *Found on Referral documentation

Date of Referral *From the uploaded document, not today's date

Medical Summary

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Allied Health or Other Reports

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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 Care Manager (if appropriate)other

Care Manager/Coordinator Email

Other Name

Other 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 and the conditions outlined within them. *

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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