NDIS SERVICE AGREEMENT FORM

For all enquiries, please call 1800 87 87 22

The compulsory fields must be completed or they cannot be processed.

Provider Name: Superior Health Care

Participant Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Delivery Address *

Please tick if you are completing this form on behalf of someone else

Client Representative Details

First Name *

Last Name *

Phone Number *

Relationship to Participant *

Email Address *

NDIS Details

NOTE: DO NOT COMPLETE THIS FORM IF YOU ARE A PLAN MANAGED OR SELF MANAGED PARTICIPANT

If you are a plan-managed or self-managed participant, you do not need to complete this form. Please process your order online and proceed to checkout.

Plan-Managed: On checkout, please add the Plan Managers email address in the 'Notes' section

Self-Managed: Please complete checkout using one of the payment methods provided. You will be issued with a tax invoice upon delivery of goods and you may claim for reimbursement for the cost of goods directly from NDIA.

NDIS Number *

Plan Start Date *

Plan Review Date *

Plan *

Agency Managed (NDIA)PACE Participant

PACE Particpants

If your new plan is managed via the PACE portal, you will need to nominate Superior Health Care to be a participant endorsed provider (PEP).

The Superior Health Care details for this process are below:

NDIS Provider Name:	Superior Health Care - 4050032854
NDIS Provider Number:	4050032854

Booking AmountIf left blank, $3,000 will be the default

Plan Manager Details

Plan Manager Name / Agency Name *

Plan Manager Contact Number *

Plan Manager Email *

I have obtained consent from the participant to make this request and provide Superior Health Care with the participant's personal and NDIS plan details. *

Signatures

Signature *

Clear

Participant/Participant Representative

Full Name *

Date *

Service Agreement

Responsibilities of Superior Health Care ( "Provider")

The Provider agrees to:

Provide 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 supports are provided.
Listen to the Participant’s feedback and resolve problems quickly.
Give the Participant the required notice if the Provider needs to end the Service Agreement.
Protect the Participant’s privacy and confidential information.

Responsibilities of Participant / Participant’s representative ("Participant")

The Participant agrees to:

Inform the Provider about how they wish the supports to be delivered to meet the Participant’s needs.
Give the Provider the required notice if the Participant needs to end the Service Agreement.
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.
To provide adequate information to the provider so a service booking can be made and funds claimed whilst remaining under budget.

Payments and Claims

If the Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement, the Participant authorises the Provider to reserve the nominated funds and claim payment for those supports from the NDIS provider portal. If the Provider is unable to claim the order amount from the NDIS provider portal, the Participant will be liable for balance on the account.

NDIS Provider Approval (Office Use Only)

Signature *

Authorised person on behalf of Provider

Name *Superior Health Care NDIS Approver

Date *

Form completed and Approved *

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