NDIS Service Agreement Please enable JavaScript in your browser to complete this form.NDIS Service Agreement 1. Parties This Service Agreement is for:Client Name *FirstLastClient Date Of Birth *NDIS Number *a participant in the National Disability Insurance Scheme (client), and is made between:Client/Client Representative Name *Practice Name *Date *2. The NDIS and this Service Agreement This Service Agreement is made for the purpose of providing supports under the clients NDIS plan. A copy of the clients NDIS Plan is/is not attached to this Service Agreement. 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. - NDIS plan to be provided to FOOT HEALTH CLINIC 3. Schedule of supports FOOT HEALTH CLINIC agrees to provide the client with Podiatry services. The supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a client NDIS supports) are the responsibility of the client / clients representative and are not included in the cost of the supports. 4. FOOT HEALTH CLINIC responsibilities Foot Health Clinic agrees to: - review the provision of supports at least annually with the client; - once agreed, provide supports that meet the client's needs at the client's preferred times; - communicate openly and honestly in a timely manner; - treat the client with courtesy and respect; - consult the client on decisions about how supports are provided; - give the client information about managing any complaints or disagreements and details of Foot Health Clinic cancellation policy; - listen to the client’s feedback and resolve problems quickly; - give the client a minimum of 24 hours notice if Foot Health Clinic has to change a scheduled appointment to provide supports; - give the client the required notice if Foot Health Clinic needs to end this Service Agreement (see "Ending this Service Agreement" below for more information); - protect the client's privacy and confidential information; - provide supports in a manner consistent with all relevant laws, including the NDIS Act 2013 and Rules, and the Australian Consumer Law; - keep accurate records on the supports provided to the client; and - will issue invoices and statements of the supports delivered to the participant as per the NDIA Terms of Business for Registered Providers as requested 5. Responsibilities of the client / client representative The client / client representative agrees to: - inform Foot Health Clinic about how they wish the supports to be delivered to meet the client needs; - treat Foot Health Clinic workers with courtesy and respect; - talk to Foot Health Clinic if the client has any concerns about the supports being provided; - give Foot Health Clinic the required notice if the client cannot make a scheduled appointment, noting that if the notice is not provided, Foot Health Clinic cancellation policy will apply; - give Foot Health Clinic the required notice if the client needs to end this Service Agreement (see 'Ending this Service Agreement' below for more information); and - let Foot Health Clinic know immediately if the client NDIS plan is suspended or replaced by a new NDIS plan, or the client stops being a participant in the NDIS. 6. Payments Foot Health Clinic will seek payment for their provision of supports after the supports have been delivered.Please select one *SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After the client receives the podiatry service / supports, the client will pay for the services on the day the service is provided and Foot Health Clinic will issue the client with a receipt. The client will then be able to make a Payment Request for reimbursement from their NDIS Plan budget. NDIA MANAGED - The client has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, Foot Health Clinic will claim payment for those supports from the NDIA. PLAN MANAGED - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Foot Health Clinic will claim payment for those supports fromPlan Manager Provider NamePlan Manager Email AddressStart Date7. 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. 8. 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. 9. Feedback, complaints and disputes If the client wishes to give Foot Health Clinic feedback or is not happy with the provision of supports and wishes to make a complaint, the participant can talk to Oliver Fawcett or Kim Edwards (Directors) or email: infofoothealthclinic.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. 10. Goods and Services Tax (GST) For the purposes of GST legislation, the Parties confirm that: - a supply of supports under this Service Agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the NDIS Act, in the client's NDIS Plan currently in effect under section 37 of the NDIS Act; - the client's NDIS Plan is expected to remain in effect during the period the supports are provided; and - the client / client representative will immediately notify the provider if the client's NDIS Plan is replaced by a new plan or the client stops being a participant in the NDIS. 11. Cancellation Policy At Foot Health Clinic we value consistent and high quality intervention. If you need to cancel an appointment it is recommended it occur before 12pm on the day before your appointment to avoid a cancellation fee. If you contact Foot Health Clinic after 12pm the day before your appointment or on the day of your appointment there will be a cancellation fee of 50% charged to your account and payment due at your next appointment. Where Foot Health Clinic cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party.Cancellation Policy *I have read & understood the cancellation policy 12. Contact details The Client Representative can be contacted on:Client/Client Representative Name *Alternative contact personAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone * Email Address of Client/Client Representative *Foot Health Clinic can be contacted on: Contact:Oliver Fawcett/Kim Edwards Clinic Phone: 07 3289 6050 Email: infofoothealthclinic.com.au Postal Address: PO Box 596, Samford Qld 4520 13. Schedule of supports I/we agree to pay for treatment/ therapy sessions provided by Foot Health Clinic through claiming against the National Disability Insurance Scheme (NDIS) service plan. Working with the NDIS we have been allocated Podiatry funding for the service year (enter service dates)Start Service Date *Finish Service DateThe Provider agrees to provide the client podiatry services for the duration of the agreement at the scheduled rate. These include: - Podiatry assessment and treatment including provision of orthotic devices and footwear as required - Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 10 minutes will be invoiced) - Assessment and trial of equipment as required - Any reports, forms or letters as required by the NDIS or requested by the client / client representative - Cancellation charges for late notice or no show appointments Foot Health Clinic reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds in your plan or the plan expires. Any service fees not met by NDIS will be covered by your client / client representative.Frequency of support *As scheduledWhere the support will be provided *ClinicHome The total funding claimed by this service over the period of this service agreement will be *$193.00Price & Payment Information Podiatry Consultations will be charged at $193.00 per hour.Details of Podiatry services: *Initial Podiatry Consultation (1 hour) Item # 15-056-0128-1-3 $193.0014. Agreement signatures The parties understand and agree to the terms and conditions of this Service Agreement.SignatureClear SignatureName of Client/Client Representative *Signed Date *Captcha *What is 7+4? Note: if you see * this denotes multiply (i.e. 11 * 8 = 11 x 8). Submit SHARE