We collect information about you for the primary purpose of providing quality supports and
services to you. We need to collect some personal information from you to ensure our
services meet your needs. If you do not provide this information, we may be unable to fully
provide these services. This information will also be used for;

• Administrative purposes for running our service
• Billing you directly, through the NDIS, or another agency if required
• Use within our service to ensure you are provided with quality supports and services
• Disclosure of information to the NDIA, the NDIS Quality and Safeguards Commission,
or other government agencies if needed
• Disclosure of information to health professionals to ensure high quality health care for
you if needed
• Disclosure to other providers, with your consent, to provide appropriate services

My Care Plan Manager is required to disclose some or all this information to NDIS and/or to
another organisation. My Care Plan Manager may also disclose your personal information
to another service provider if you commence working with another service provider.
Disclosure to other government departments, government authorities and researchers may
also occur for the purpose of ensuring that you are provided with good quality services and
assistance. If you are a NDIS participant, your personal information may be used to give you
the services and/or payments that you need.

• Have read the above information and understand the reasons for the collection of my
personal information and the ways in which the information may be used and
disclosed and I agree to that use and disclosure.
• Understand that this consent is valid only for the time specified.

• Understand that it is my choice as to what information I provide, and that withholding
or falsifying information might act against the best interests of the supports and
services I receive.
• Am aware that I can access my personal information and shift notes on request and if
necessary, correct any information I believe to be inaccurate.
• Understand that if, in exceptional circumstances, access is denied for legitimate
purposes, that the reasons for this and possible remedies will be made available to me.
• Have been provided with or have been given an opportunity to obtain a copy of
Privacy Policy.

I hereby give consent to My Care Plan Manager to exchange my personal information either
verbal and/or written and/or recorded material in audio and/or visual format, to / from;

My Care Plan Manager and Authorised personnel

• Psychologist
• NDIA / NDIS
• Family members
• Health practitioner i.e. nurse, family doctor/General Practitioner or medical specialist
• Support Coordinator / Case Manager
• Quality Systems Auditor(s): File review and interview
• Prospective and existing Support workers
• Other (please specify below)

You may contact us by email, mail or phone using the details provided at the top of this
page. You have the right to gain access to the information we hold about you. Our privacy
policy (available upon request) contains information on how you may request access to,
and correction of, your personal information and how you may complaint about a breach
of your privacy and how we will deal with such a complaint. We need to collect information
about you for the primary purpose of providing quality supports and services.

In order to fully provide these services, we need to collect some personal information from
you. This information will also be used for the administrative purposes of running the
practice such as billing you or through the NDIS. Information will be used within the service
for planning and managing your plans and supports.

We may disclose information regarding you to other service providers or health
professionals only with your consent. We will not disclose your information to commercial
companies, however specific service or product information as deemed suitable for your
management, may be forwarded to you by us, unless you instruct us not to forward this
type of information. Your written consent will be obtained at the start of any new planned
activities. We do not disclose your personal information to overseas recipients.

File information is stored securely and access only by our workers. We take all reasonable
steps to ensure that information collected about you is accurate, complete, and up to date.
You may have access to your information on request and if you believe that any of the
information is inaccurate, we may amend it accordingly. If you do not provide relevant
personal information, in part or in full, this may result in the provision of incomplete
supports or services which may impact on your plans and goals. Any concerns you may
have about this statement or the information we store about you can be directed to our
Director.