Service Agreement

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This Service Agreement is made between the Participant and the Provider - Complete Healthcare Connect. This Service Agreement can be made between the Participant and/or the Participant’s representative and Complete Healthcare Connect. The Participant’s representative can be a family member, friend, or someone close to the Participant who can manage the funding for supports. Some details on this Service Agreement may have been filled out before, please submit the information again to reconfirm.

Participant Details

Participant's Name*

First Name Last Name

Date of Birth*

Participant’s diagnosis*

Participant's attendance*

Participant is able to arrive for appointment themselves

Participant needs to be dropped off/picked up

Participant needs to be accompanied by an adult

Funding Details

Funding Method*

NDIS

Home Care Package

Private

Other (please provide email)

Funded by:*

Agency Managed (NDIA)

Plan Managed

Self Managed

Participant’s NDIS Number*

Plan Start Date*

Plan Review Date*

Plan Manager Name*

Email address for invoices*

Plan Nominee / Guardian Details

Participant's Representative (if applicable)

First Name Last Name

Relationship

Phone Number

Support Coordinator (if applicable):

Other support services (optional):

Risk Assessment

Potential Risks*

Risk of injury or death to the person or others

Homelessness

Substance abuse

Loss of placement (i.e. school, accommodation, day service)

School or Service placement interruption (temporary)

Police/Criminal justice contact

Sexual

Others (please describe below)

None of the above

Behavior of Concern*

Verbal outburst

Property damage

Self-injurious behavior

Other (please describe below)

None of the above

Other potential risks or behavior of concern

Risk rate*

Low

Medium

High

Treatment Control Measures

Responsibility*

Review (re-assessment)

Plan-specified goals & clinical goals

Plan-specified Goals*

Clinical Goals/ Objectives (with the aim of achieving)*

Planned Interventions & Finance

A Revised Planned Interventions & Finances Agreement will be composed by the clinician post the initial appointment to provide a more detailed breakdown of the costs associated. A copy will be sent to client/representative to sign and approve.

Please select the required services*

Physio - $193.99 per hour

OT - $193.99 per hour

Speech Therapy - $193.99 per hour

Psychology - $214.41 per hour

Podiatry - $193.99 per hour

Support Coordination - $100.14 per hour

Please select the required services*

Physio - $160 per hour

OT - $180 per hour

Speech Therapy - $180 per hour

Psychology - $170 per hour

Podiatry - $150 per hour

Additional Notes:

Total funding available for this SA:*

Travel cost includes travel time and non-labour costs associated with the travel and is determined via the NDIS guidelines, charged in 5-minute increments at the:

Therapist hourly rate of $193.99, and Support Coordination hourly rate of $100.14

In addition to $1.00 per allowance km for their travel distance).

Short Notice Cancellations / Missed appointments / Unconfirmed appointments will be charged

Appointments will be put on hold and moved to waiting list in case of 3 consecutive Short Notice Cancellations / Missed appointments / Unconfirmed appointments

Emergency or Disaster Arrangements

Arrangements for providing supports in the event of an emergency or disaster:

Clinicians will follow the control measure listed on Emergency or Disaster Management Plan to ensure Participant’s safety, health and wellbeing

Admin will attempt to reschedule appointments in situations where:

Clinician is on leave or is unwell

Client is on leave or is unwell

Agreement Review Date

Agreement Review Date will be mentioned on the Revised Planned Intervention and Finances Agreement, which will be completed by the clinician post the initial appointment

Participant's Consent

I want to acknowledge that Complete Healthcare Connect Australia / In-home & Community Care Plus has advised me of the following:

List

Participant's Consent

At Complete Healthcare Connect, we are committed to protect your information and ensure they are identifiable, accurately recorded, current, confidential, easily accessible to the participant and appropriately utilised by relevant workers.

The Provider requires to collect some personal information about the Participant to provide the highest quality of services and supports.

The Participant has the right to gain access to the information the Provider hold about the Participant. The Privacy & Confidentiality Policy is also available in the Participant Handbook which is provided to the participant during their initial appointment. This policy provides information on how participants may request access to their personal information.

I,*

Date of Birth*

am aware that Complete Healthcare Connect, as my NDIS service provider, may need to communicate information to and share documents with involved parties.

This informant is for all information relevant to my NDIS plan in the year ahead and associated activities. It is not for medical or personal health information.

Therefore, I give consent to Complete Healthcare Connect to communicate directly and share documents with the below parties; (please tick all applicable)

List of parties:

My Local Area Coordinator (LAC)

My Plan Manager Team

My Support Coordinator

My Support Worker/s

My Carer

Other Parties

Name*

Phone Number*

Email*

Company Name*

Other parties (please state):*

NDIS Client name/Guardian/ Carer/Power of Attorney:*

Signature*

Date of agreement*

Terms and Conditions

Scope

This Service Agreement is made against the National Disability Insurance Scheme (NDIS) rules and goals. This Service Agreement has been developed to ensure that the participant and provider have an agreed expectation of the supports in line with the NDIS Plan to:

support the independence and social and economic participation of people with disability

provide reasonable and necessary supports, including early intervention supports, for participants in the Scheme launch

enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports

facilitate the development of a nationally consistent approach to the access to, and the planning and funding of, support for people with disability

promote the provision of high-quality and innovative supports to people with disability

raise community awareness of the issues that affect the social and economic participation of people with disability and helps with greater community inclusion of people with disability

Service & Support Schedule

Agreed services and supports between the Participant and the Provider is documented in this service agreement. Ongoing supports from allied health professionals within Complete Healthcare Connect include 1:1 therapy, resource development, interdisciplinary meetings, all communication with relevant parties (including NDIS), therapy plans, reports, letters and travel, and are directly linked to the participant’s goals.

AT Disclaimer

The participant understands and accepts their liability as part of an Assistive Technology application. In the event any Assistive Technology application is deemed “not reasonable and necessary” according NDIS guidelines, the participant accepts any costs or fees associated with the reimbursement process to NDIS.

Continuity of Supports

Participant needs, support requirements, strengths, goals, culture, diversity, values, and beliefs specified by the participant including the inputs from their family/support network are identified during the initial assessment process and documented in the NDIS Therapy Plan.

Participant’s preferences such as the same language, same culture or specific criteria will be considered, where possible.

Complete Healthcare Connect is committed to the continuous support for the Participant, and in the event of worker absence or vacancy, a suitably qualified and experienced person will perform the role.

An alternative arrangement will be set with the participant approval, in case of unavoidable interruptions.

With the participant’s consent or direction, Complete Healthcare Connect will develop and maintain links through collaboration with other providers to share information and meet participant needs. That information will be recorded in the NDIS Therapy Plan.

Change

If changes to the supports or delivery services are required, the Parties agree to discuss and review this Service Agreement. If applicable, changes in this Service Agreementwill be in writing, signed and dated by both Parties.

Withdrawn

This Service Agreementcan be withdrawn at any time with 4 weeks’ formal notice.

The requirement of notice will be waived if either party breaches this Service Agreement.

Access to supports required by the participant will not be withdrawn or denied solely based on dignity of risk choice that has been made by the participant.

A handover report (min 3 hrs at $193.99) will be completed by clinician and forwarded to new provider or forwarded to participant to handover to new provider.

Fees and Charges

Costs

All fees comply with the NDIS price guide and may change during this Service Agreement in accordance with NDIS price guide changes. If fees do change the participant will be notified in writing.

Please refer to the NDIS Price Guide

All prices are GST inclusive (if applicable) and include the cost of providing the supports.

Payment

The participant has agreed to pay to the Provider for their services and supports on the day and after the Participant’s attendance as below.

SELF-MANAGED FUNDING:

The Participant has chosen to Self-Manage the funding for NDIS supports provided under this Service Agreement.

After providing those supports, the Provider will send the Participant an invoice for those supports.

The Participant can pay the invoice by EFT, credit card, cash or cheque within 7 days with the terms outlined in the invoice.

If the invoice remains unpaid after 2 weeks, services will cease until payment of all invoices is made.

NOMINEE MANAGED FUNDING:

The Participant’s Nominee manages the funding for supports provided under this Service Agreement.

After providing those supports, the Provider will send the Participant’s Nominee an invoice for those supports for the Participant’s Nominee to pay.

The Participant’s Nominee can pay the invoice by EFT, credit card, cash or cheque within 7 days with the terms outlined in the invoice.

If the invoice remains unpaid after 2 weeks, services will cease until payment of all invoices is made.

NDIA MANAGED FUNDING:

The Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement.

After providing those supports, the Provider will claim payment for those supports from the NDIA.

REGISTERED PLAN MANAGED PROVIDER:

The Participant has nominated a Registered Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement.

After providing those supports, the Provider will claim payment for those supports from the Registered Plan Management Provider.

If the invoice remains unpaid after 2 weeks, services will cease until payment of all invoices is made.

Cancellation

CANCELLATION BY THE PARTICIPANT:

If a participant makes a short-notice cancellation, which is after 48 hours before the service. The provider may charge up to 100% of the agreed price for their time and travel.

A cancellation is a short notice cancellation if the participant does not show up for scheduled support within a reasonable time or is not present at the agreed place and within a reasonable time when the provider is travelling to deliver the support.

Cancellations are accepted by email, text or phone call.

Please refer to the NDIS Price Guide

Additional Expense

Additional expenses that are not included as part of a Participant’s NDIS supports are the responsibility of the participant and are not included in the cost of the supports. Examples include: entrance fees, parking fees.

Agreement Signatures

The Parties agree to the terms and conditions of this Service Agreement and agree to receiving the NDIS welcome pack with Handbook.

Participant or Participant's Representative (if applicable)

Name*

NDIS Number*

Signature*

Date*

Provider

Complete Healthcare Connect

Name of Authorised Person

Signature

Date

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