NDIS Service Agreement - General

If you need assistance with this form from your parent/guardian please ensure they are with you to complete and submit
If you have any questions about this consent form please discuss with your worker during your appointment

Participant Name *

Participant Number

Date of Birth *

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Nominee Name (if applicable)

Service Agreement Outline

This service agreement outlines the consent, expectations and responsibilities of Me (the client) and Country & Outback Health.
This service agreement should be read and explained alongside information supplied in your welcome pack:

• Country & Outback Health Client Information Booklet
• My NDIS Services Costs Brochure
• Service Information Brochures (about our programs)
• Your current NDIS Booking Form (When you will receive services and how much they will cost)
• Your current My Support Plan (What supports you will receive to achieve your goals)

In addition to information contained in the above, you can also expect Country & Outback Health staff will:

• Provide supports consistent with all relevant laws including the National Disability Insurance Scheme Act 2013 and rules, Terms of Business for Registered Providers, and the Australian Consumer Law.
• Give you the required notice if Country & Outback Health needs to end the Service Agreement (see ‘Ending this Agreement’) as set out below for more information.

In addition to information contained in the above, you are required to:

• Give Country & Outback Health the required notice to end the Service Agreement should you wish to cease this Agreement. See ‘Ending this Agreement’ (below).
• Notify Country & Outback Health immediately if your NDIS plan is suspended or replaced by a new NDIS plan, you have spent all the funding provided under your NDIS package and are able to fund continued services by alternative means or you stop being a NDIS Participant.

Consent

• I consent for Country & Outback Health clinicians and support workers to provide support to me, which may include a range of assessments, interventions or support services.
• I give permission for staff from Country & Outback Health to release and exchange information to assist in my services (if yes, please specify below)

Please specify information to be released and exchanged to assist your services

Please specify any limitations to exchanging information with those nominated:

Consent (cont.)

• I consent for Country & Outback Health clinicians and support workers to provide support to me, which may include a range of assessments, interventions or support services.
• I give permission for staff from Country & Outback Health to release and exchange information to assist in my services (if yes, please specify below)
• I understand that all information collected by Country & Outback Health will be treated in a confidential manner and stored securely in electronic databases.
• I understand that there are limitations to confidentiality and Country & Outback Health may provide information about me where there is a legal obligation to do so or if there is an immediate or specified risk of harm to myself or another person.
• I understand that the service is voluntary, and consent is valid until the time of exit from Country & Outback Health services and I have the right to withhold or withdraw consent at any time.
• I understand information collected by Country & Outback Health may be accessed for internal and external quality assurance purposes.

Optional OPT OUT

• I do not want to be contacted to participate in audit activities from time to time.

Complaints and the NDIS Commission

Country & Outback Health is committed to maintaining a high standard of service and we welcome all feedback. Your Client Information Booklet explains how you can provide feedback on your experiences with us, including how to make a complaint.
As an NDIS participant, you have the right to make a complaint directly with the NDIS Commission, an independent agency established to improve the quality and safety of NDIS supports and services. For more information visit their website: https://www.ndiscommission.gov.au/about/complaints or call them on 1800 035 544 (free call from landlines) or TTY 133 677.

Advocacy

An advocate can enable and support you by helping you understand your rights, listen to your concerns and discuss your options for raising that concern. They can assist with negotiating changes to your plan, give advice and support when dealing with service providers and help you overcome any barriers that may impact on your ability to participate in your community.
Disability advocacy organisations include Advocacy for Disability Access and Inclusion https://advocacyfordisability.org.au/ phone (08) 8340 4450 and Disability Advocacy and Complaints Service of South Australia Inc https://www.dacssa.org.au/ phone (08) 7122 6030

Conflict of Interest

Country & Outback Health provide a range of different services for NDIS participants. This means we may have a real or perceived conflict of interest, particularly if we are providing you with more than one service. Country & Outback Health is committed to ensuring we are open and transparent and actively manage any real or perceived conflicts of interest. This includes ensuring you are aware of your rights of choice and control and that you are making your own decision on the services to best meet your needs. You have a right to know and understand how we do this and how we manage this – if you would like to receive this information, please contact us.

Incident Management

Country & Outback Health treat your safety and wellbeing as a priority. If we become aware of any incidents involving you, we will let you know and seek your input and we will investigate accordingly and appropriately and keep you informed of the process. We will also report the incident to the NDIS commission within the required timelines. We may be required to report the incident to other statutory bodies, and will inform you of this.

Ending this agreement

If you want to end this Service Agreement, you should give us 28 days’ notice – in this time Country & Outback Health will finalise outstanding payments, release service bookings, complete any reports and supply this information to you. Face to face services can be stopped any time you would like. If Country & Outback Health need to end this agreement, we will give you 28 days’ notice. If either party fails to meet their responsibilities, or the terms set out in this Service Agreement or where there is a risk to the safety to you, or Country & Outback Health staff, then the requirement of notice will be waived. This agreement will remain current until replaced with a new / updated service agreement.

Confirmation

Full Name *

Signature *

Clear Signature

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Relationship (if not participant)

Date *

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Name

Submit

Click HERE for how to make a complaint about your NDIS service