Participant
First Name
Preferred Name
Last Name
Phone Number
Email
Postal Address
Residential Address
NDIS Number
Date of Birth
NDIA Plan Start Date
NDIA Plan End Date
Preferred method of contact
if you require an interpreter, which language?
Authorised Plan Nominee (Parent / Carer / Etc.)
First Name
Preferred Name
Last Name
Phone Number
Email
Postal Address
Residential Address
Preferred method of contact
Relationship to Participant?
If you require an interpreter, which language?
Support Coordinator
First Name
Last Name
Organisation
Phone Number
Email
Preferred method of contact
If you require an interpreter, which language?
NDIA Contact
First Name
Last Name
Phone Number
Email
Providers.
Service Agreement
This Service Agreement is between Life Balance NDIS Plan Management (Life Balance) and Carer / Parents Name
acting as the authorised Plan Nominee for Participants name
This Service Agreement is made for the purpose of Life Balance providing plan management
(financial administration) to the Participant in accordance with the Participant’s National
Disability Insurance Scheme plan (NDIS plan).
Definitions
Life Balance NDIS Plan Management ( Life Balance)
is a trading name of The Trustee for the Fiorillo Family Trust (ABN 33 842 811 600).
The Trustee for the Fiorillo Family Trust
is a registered NDIA provider under the National Disability Insurance Scheme Act (2013)(Cth),(the NDIS Act).
NDIA
The National Disability Insurance Agency is the organisation which manages the NDIS.
NDIS
The National Disability Insurance Scheme was established under the NDIS Act. The aims of the NDIS include:
Support the independence and social economic participation of people with disability; and
Provide reasonable and necessary supports, including early intervention supports for participants; and
Enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their support services.
This Service Agreement is made in the context and purpose of the NDIS.
NDIS PLAN The NDIS plan is a written agreement between the Participant, and the NDIA
stating the Participant’s goals and needs, and the reasonable and necessary supports the
NDIA will fund. Each participant has their own individual plan.
NOMINEE The person appointed under the NDIS Act to act on behalf of the Participant.
PARTICIPANT Tin this Service Agreement, the Participant is the person who has met the NDIS requirements and has a current NDIS plan. Where applicable, in this Service Agreement,
Participant, may also refer to Nominee.
PLAN MANAGEMENT is when a service funded through the NDIS to assist and support participants to manage their NDIS plan funding.
PROVIDER A person, business or organisation who delivers a support or a product to the Participant.
Commencement + Duration of Service Agreement
This Service Agreement will commence on Date of agreement being filled out
This Service Agreement will be ongoing for the duration of the time Life Balance provides Plan
Management services to the Participant within the scope of their NDIS Plan at the time of
signing this Service Agreement and any future NDIS plans, including after an NDIA plan review
or renewal, unless either party notifies the other party of their intention to end this Service
Agreement as per the terms of this Service Agreement
To minimise disruption to service during any changes to the Participant’s NDIS Plan, including
any new plans, Life Balance will monitor the NDIS portal and create a new service booking
and budget based on the information provided on the NDIS portal. A detailed budget
breakdown will be provided following receipt of a copy of the Participant’s changed or new
plan.
Ending This Agreement
Should either party wish to end this Service Agreement they must notify the other party in
writing confirming they wish to cease this Service Agreement.
Life Balance will cancel any service bookings within 7 business days of receiving written
notice. Invoices received by Life Balance after receipt of the written notice of
cancellation will not be processed by Life Balance and will become the responsibility
of the Participant.
If either party seriously breaches this Service Agreement the requirement of this notice will be
waived
Responsibilities of Life Balance NDIS Plan Management
Life Balance NDIS Plan Management will:
Provide financial intermediary services to the Participant:
Manage and monitor the Participant’s NDIS plan managed funding;
Maintain accurate records of plan managed funded services provided to the Participant;
Produce monthly statements for the Participant showing the expenditure and balance of the Participant’s plan managed funding;
Alert the Participant about any queries or concerns with an invoice;
Alert the Participant about any potential under-utilisation or exceeding of plan managed funds;
Check-in with the Participant at regular intervals throughout the duration of heir plan to review and discuss the progress and status of the Participant’s plan managed supports and funding;
For each new NDIS Plan within the scope of this Service Agreement:
Meet with the Participant to discuss a budget breakdown and any changes of note for plan managed funds.
Set up the new plan and budgets on the NDIS portal.
Communicate with the Participant openly, honestly in a timely manner;
Treat the Participant with courtesy and respect;
Deliver services in a fair, equitable and transparent manner
Consult the Participant on decisions about how services are provided;
Provide the Participant information about managing any complaints or disagreements with providers;
Listen to the Participant’s feedback and resolve problems quickly and in a professional
manner;
Protect the Participant’s privacy and confidential information in accordance with Life
Balance’s Privacy Policy, the Privacy Act 1988 and the Australian Privacy Principles;
Provide services in a manner consistent with all relevant laws, including the National
Disability Insurance Scheme Act 2013 and rules, and Australian Consumer Law
Responsibilities of Participant
The Participant will:
Provide Life Balance with true and accurate information;
Only purchase supports deemed as reasonable and necessary within the scope and context of their NDIS Plan;
Give Life Balance permission to contact or be contacted to discuss any service provision or invoice queries directly with the respective provider, including the NDIA or LAC Partnership organisations;
Let Life Balance know immediately if their NDIS Plan has been suspended or replaced
by a new NDIS Plan, or if they cease being a participant of the NDIS.
If required for auditing or regulatory purposes, be willing to be contacted and have their
records reviewed by authorised and accredited third parties or legislative bodies. The
Participant may opt out of this at any time.
Inform Life Balance about how they wish their services to be delivered to meet their
goals and needs;
Treat Life Balance with courtesy and respect;
Let Life Balance know if they have any concerns about the services being provided;
Plan Management Payments
The plan management funding is separate and in addition to the funds allocated for other
supports. This Service Agreement requires the Participant to have Plan Management stated
in their NDIS Plan.
Plan management funding includes both a plan management establishment fee, and a
monthly financial administration fee. The establishment fee covers the cost for the establishment of financial intermediary services between the Participant and CPM. The
monthly financial administration fee covers the ongoing management of the Participant’s Plan Managed supports funds, including processing of invoices, monitoring and reporting.
Life Balance will invoice the NDIA directly on a monthly basis for the Plan Management services provided to the Participant.
Plan Management – Financial Administration
$104.45 p/month
Where the NDIA amend the plan management fees, Life Balance will automatically update
and apply the new fee rates in accordance with the NDIS Price Guide. There will be no action
required by or direct cost to the Participant.
By signing this Service Agreement, the Participant is confirming they have Plan Management
funding in their NDIS Plan.
Processing + Payments Provider Invoices + Receipts
Life Balance will facilitate and manage the NDIS claims and payment of provider
invoices and receipts on behalf of the Participant.
Invoices received by Life Balance for the delivery of services to the Participant by any
pre-approved or pre-approval providers will be processed within 3 business days of receipt.
Where Life Balance does not have the authority to process a provider invoice, Life Balance will
seek confirmation and approval from the Participant. The Participant may notify Life Balance
in writing at any time within the duration of this Service Agreement of any addition to or
removal of a pre-approved or pre approval provider.
Receipts received by Life Balance from the Participant for reimbursement of payment for
services delivered will be processed within 2 business days of Life Balance receiving a copy
of the provider’s receipt or statement from the Participant.
Life Balance will only process invoices and receipts deemed as necessary and reasonable
supports in line with the Participants NDIS plan and only claim and pay up to the maximum
rate as specified in the NDIS Price Guide.
Indemnity
The Participant must indemnify and hold Life Balance harmless from and against all
claims and losses arising from loss, damage, expense, liability, injury to the Participant, by
reason of or arising out of the services support to the Participant by Life Balance within or
outside of the scope of this Service Agreement.
Changes to This Agreement
If changes to the service or 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.
Feedback, Complaints + Disputes
If the Participant wishes to give feedback or make a complaint, the Participant can contact
Life Balance via email admin@lifebalancepm.com.au or telephone 1800 998 994.
If the Participant is not satisfied with the outcome of their complaint or does not want to talk
to Life Balance, the Participant can contact the NDIS Quality and Safeguards Commission
via
Phone: 1800 035 544 or TTY 133 677. Interpreters can be arranged.
National Relay Service: ask for 1800 035 544.
Completing a complaint contact form on their website at www.ndiscommission.gov.au
Goods + Services Tax (GST)
For the purposes of GST legislation, the parties confirm that:
A supply of services under this agreement is a supply of one or more of the
reasonable and necessary services specified in the statement included, under
subsection 33(2) of the National Disability Insurance Scheme Act 2013 (NDIS Act), in
the Participant’s NDIS Plan currently in effect under section 37 of the NDIS Act;
The Participant’s NDIS Plan is expected to remain in effect during the period the
services are provided; and
The Participant will immediately notify Life Balance if their NDIS Plan is replaced by a new
plan or they cease being a participant in the NDIS.
Agreement Signatures
Parties Signatures
The Parties agree to the terms and conditions of this Service Agreement.
Participant // Authorised Plan Nominee:
Full Name
Date
Authorised Person from Life Balance NDIS Plan Management
Full Name
Date
Consent for your NDIS information
Consent is a record of the permission you have given.
If you’re 18 or older, you have the right to make decisions about your business with the NDIS. That’s
why we need a record of your consent before we share your information with anyone else or let
someone else do things for you.
Please use this form if you want to give your consent:
for the National Disability Insurance Agency (NDIA) to share your National Disability Insurance
Scheme (NDIS) information with a person or organisation you choose • to allow another person
or organisation (third party) to do things for you with the NDIS.
For example, you might want to give consent for a family member who supports you to view your
current plan and submit a home modification request for you.
You can give consent if you’re the:
applicant
participant
child representative or plan nominee for the participant
legally appointed decision maker for an applicant
When we say applicant, we mean someone who is applying to the NDIS.
You don’t have to use this form to give your consent. You can let us know over the phone by calling
1800 800 110 or by contacting us in any of the ways listed under How do I return this form to the
NDIA.
We’ll only share your personal information if you’ve given your consent to the NDIA to do this. Or, if
we’re required or authorised to disclose your information by law.
You can take away your consent at any time. You can let us know by mail, email, in person or over
the phone that you no longer consent to us sharing information on your behalf.
How do I return this form to the NDIA?
There are a few ways you can return this form to us:
Email for applicants: NAT@ndis.gov.au Email for participants: enquiries@ndis.gov.au Mail: NDIA, GPO Box 700, Canberra ACT 2601In person: Visit a local area coordinator, early childhood partner or NDIS office in your area.
Full name
Date of birth
NDIS number
Contact Phone Number
Contact Email
Once you have completed Part A (above):
If you’re the applicant or participant, complete Part C
then sign the declaration in Part D.
If you’re the child representative, plan nominee or other legally appointed decision maker,
complete Part B and Part C . You’ll then need to sign the declaration in Part D.
Part B: Child representative, plan nominee, legally appointed decision maker
details
Please provide your details if you’re completing this form on behalf of the applicant
or participant:
under 18 years for whom you are a child representative, or
for whom you are a plan nominee, or
for whom you are a legally appointed decision maker (for example, a guardian).
Your full name
Your date of birth
Your phone number
Your email
What is your relationship to the participant/ the applicant e.g. child representative, plan nominee, legally appointed decision maker
Employee number or logon (if you are completing this form as part of your job)
Part C: Give consent
Please complete the details of the person or organisation you’re giving consent to.
If there are more people or organisations you want to give consent to, you’ll need to provide
consent for each one individually. Or, you can give your consent over the phone by calling 1800
800 110. You can also contact us in any of the ways listed under How do I return this form to the
NDIA
Please mark the correct box and complete the details below.
First name
Surname
Is this person a NDIS provider or do Surname
If you answered yes to this question, what is the name of the NDIS provider?
Phone
Email
Address (include street or PO Box number, suburb, state and postcode)
Relationship to participant/applicant
Consent is limited to 2 key contacts in the organisation. If your key contacts change, let us know
so we can update who in the organisation you have given consent to. Contact us by
calling 1800 800 110 or in any of the ways listed under How do I return this form to the NDIA
Organisation name
Key contact’s first name
Key contact’s surname
Key contact’s position title (if applicable)
Phone
Email
Address (include street or PO Box number, suburb, state and postcode)
I am providing consent for the person named in section C to have the following types of
consent
Are there other things you want the person to do on your behalf, or information you want to share? If so, please tell us what this is below
We’ll do our best to include these other things. If we’re unable to do this, we’ll let you know and
explain why.
Date
Part D: Your declaration
This part needs to be signed by whoever completes this form. This may be the participant,
applicant or child representative, plan nominee or legally appointed decision maker.
I confirm that:
I understand I can get further information about how the NDIA handles my personal information
from the Privacy Notice or Privacy Policy on the NDIS website. I can find this information on the
NDIS website.
I understand I have given the NDIA consent to give information about me to the third party or
parties I have listed at Part C on this form.
I understand that the third party or parties I have given consent to will be able to access my
information and/or act on my behalf.
I understand I can take away or change my consent to share information and/or my consent
for a third party to act on my behalf at any time.
I confirm the information provided in this form is complete and correct.
I understand giving
false or misleading information is a serious offence.
I understand this information is protected
by law and the NDIA can only share it with someone else where Commonwealth law allows, or requires it, or where I give consent.
I
have given my consent freely and no one has pressured me into doing so.
You can find out more about how we collect, use and disclose your personal and sensitive information
on our website (ndis.gov.au). Select ‘About’, then select ‘Policies’, then ‘Freedom of Information’,
then ‘Privacy’ from the menu on the right.
If we don’t agree to your request, we’ll let you know and explain why.
Please sign here to give your consent as indicated in this form.
Name
Date
Submit
