Revised Planned Intervention and Finances "*" indicates required fields Revised Planned Interventions & Finances This is a Revised Planned Interventions & Finances Agreement which is generated by the clinician post the initial appointment to provide a more detailed breakdown of the costs associated. This needs to be signed and approved by the client/representative. Participant DetailsParticipant's Name* First Name Last Name Date of Birth* Day Month Year Funding Method* Private paying client NDIS funded Other Participant’s NDIS Number*Date of Agreement* Day Month Year Agreement Review Date* Day Month Year Revised Planned Interventions & FinancesList of services - to add more simply click the + button*Description of ServiceRateTotal Add RemoveAdditional Notes:Total Requested 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 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. 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. CANCELLATION BY THE PROVIDER: Where a provider has a short notice cancellation (or no show) they can recover 90% of the fee associated with the activity, subject to the terms of the service agreement with the participant. 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) NDIS Client name/Guardian/ Carer/Power of Attorney:* NDIS NumberSignatureDate of Agreement Day Month Year Provider Complete Healthcare ConnectName of Clinician/Authorised Person SignatureDate of Agreement Day Month Year CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
