• Plan Management Service Agreement, Consent To Share Information Form and Risk Assessment

  • NDIS Participant Details

  • NDIS Plan Nominees/ Representatives/Guardians Details

  • NDIS Plan Management Service Agreement

  • This Service Agreement is for NDIS plan participant mentioned above and is made between NDIS Plan Participant and/or Nominees/ Representatives/Guardians and My Care Plan Manager ABN: 66825073525, NDIS Provider No. 4050074147. This Service agreement is for the period of current NDIS plan start date and end date

    Service Provision

    The Provider agrees to provide the Participant a Plan Management service under capacity building budget in subcategory of CB choice and Control for the period stated in the Participant’s NDIS Plan.

    Purpose of Service Agreement

    This Service Agreement is established to provide supports as outlined in the Participant’s National Disability Insurance Scheme (NDIS) plan. Supports include services, products, or equipment supplied by the Provider under this agreement.

    The Parties acknowledge that this Service Agreement is created within the framework of the NDIS, which aims to:

    (i) Promote the independence and social and economic participation of individuals with disabilities, and

    (ii) Empower individuals with disabilities to exercise choice and control in achieving their goals and in the planning and delivery of their supports.


    By nominating My Care Plan Manager to provide plan management services and manage the funding we will claim from the NDIA portal for funding up to the amounts specified in the support category and budget approved in the Participant’s current NDIS plan. After these supports are delivered, the service provider or Participant/nominated representative will be required to forward invoices for payment to My Care Plan Manager – by email to Invoices@mcpm.net.au

    My Care Plan Manager will pay invoices once funds have been received for NDIA. Payment of invoices will be within 14 days of receipt of invoice.

    My Care Plan Manager will claim directly from the NDIA an NDIA gazetted monthly fee for the provision of support as agreed in Schedule of Supports – Improved Life Choices upon signing of the service agreement.

    Rights & Responsibilities

    My Care Plan Manager has an obligation to uphold the rights of people with disabilities under the United Nations Convention on the Rights of Persons with Disabilities.

    This section outlines My Care Plan Manager rights and responsibilities and the Clients rights and responsibilities.

    Any breach by either party of another person’s rights and responsibilities can result in cancellation of the Service Agreement.

    My Care Plan Manager Responsibilities:

    • Provide financial intermediary services
    • Reconcile client balances
    • Pay supplier invoices on behalf of client
    • Process client reimbursement claims
    • Track expenditure against client budget
    • Provide monthly statements of expenditure and available funding upon request
    • Assist with purchases where appropriate
    • Trouble shooting
    • Client liaison – emails, phone calls etc
    • Consult the Participant/nominated representative on request, regarding decisions about how funds are spent
    • Communicate openly and honestly in a timely manner
    • Treat the Participant/nominated representative with courtesy and respect
    • Listen to the Participant/nominated representative’s feedback and resolve problems quickly
    • Protect the Participant’s privacy and confidential information
    • Provide Supports in a manner consistent with all relevant laws, including but not limited to the National Disability Insurance Scheme Act 2013, its associated rules and regulations, and the Australian Consumer Law.
    • Keep accurate records of the Supports provided to the Participant and periodically issue tax invoices for the Supports delivered to the Participant.
    • Advise the Participant of any delays in the delivery of Supports.

    Client Responsibilities:

    I agree to:

    • Forward invoices for payment within a timely manner and before the due date
    • Take due steps to provide information as requested by My Care Plan Manager in a timely manner
    • Treat My Care Plan Manager staff with courtesy and respect
    • Discuss any concerns about our service with My Care Plan Manager
    • Advise My Care Plan Manager immediately if the Participant’s NDIS plan is suspended or replaced by a new NDIS plan, or the Participant stops being a participant in the NDIS.
    • Adhere to the guidelines of the Participant’s plan.
    • Ensure there are sufficient funds in the Participant’s budget to purchase the requested Supports.
    • Inform the Provider of any changes in personal circumstances that may affect the delivery of Supports.
    • Communicate with the Provider in a timely manner if there are any concerns about the Supports being provided.
    • Provide 24 hours' notice before canceling any booked appointments that require a meeting with the service provider.
    • Give the Provider the required notice if the Participant seeks to end the Service Agreement.

    Schedule of Support

    MCPM will directly claim a set-up fee (if applicable) and a monthly fee from the NDIA for the provision of support as agreed in the Schedule of Supports. MCPM's current fee structure includes the following line items:

    MCPM will charge according to the pricing set by the NDIA in the NDIS Pricing Guide at the time the charges are applied. This includes the Plan Management and Financial Capacity Building – Set Up Costs (Support Item Number 14_033_0127_8_3) and the Plan Management – Financial Administration – Monthly Fee (Support Item Number 14_034_0127_8_3), as well as any other relevant support items required to provide the service.

    And/or As per The NDIS Pricing Guide is available on the NDIS website for plan management service.

    Prices are subject to change based on market trends and cost changes, typically identified through an Annual Price Review conducted by the NDIA before each new financial year. Any new prices are outlined in an updated NDIS Price Guide, effective from July 1st each year. NDIS Plan funding is adjusted to reflect these changes. Note that the NDIA may also change prices outside of the Annual Review process.

    Additional expenses are the responsibility of the Participant and/or their Plan representative/nominee/guardian and are not included in the cost of the Supports.

    The Provider must inform the Participant and/or their plan representative/nominee/guardian before incurring any costs beyond those set out in the Schedule of Supports.

    Supply of Supports

    A supply of Supports under this Service Agreement is a supply of one or more reasonable and necessary supports specified in the statement of supports 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 and/or the Plan Representative/Nominee/Guardian will immediately notify MCPM if the Participant’s NDIS Plan is replaced by a new plan or the Participant stops being a participant in the NDIS; and

    • The Participant’s NDIS plan is expected to remain in effect during the period the supports are provided.

    Plan Management Process

    • Access service from service provider of your choice
    • Sign up with MY Care Plan Manager
    • My Care Plan Manager receive invoices from service provider
    • We Validate, review and processed invoices in accordance with the NDIS price guide
    • We send invoices for your approval
    • Resolve any invoice related queries
    • Claiming invoices for payment via NDIS portal
    • Pay invoices to service providers on your behalf within 2-5 business working days.
    • Keeping accurate records for audit purpose and plan review
    • Provide monthly overview of plan expenditure and remaining balance

    Amending this Service Agreement

    Parties must notify each other of any intent to modify this agreement within one month. Any changes to this Service Agreement, including Support provisions, must be in writing, signed, and dated by the Parties. Amendments that do not adhere to these formalities will be considered null and void.

    Privacy & Confidentiality

    To ensure Clients rights to privacy and confidentiality are upheld, My Care Plan Manager has developed a privacy and confidentiality policy that must be read and signed by all staff prior to commencing employment with My Care Plan Manager.

    Under the Client Service Agreement, the following confidentiality clauses apply:

    1. Obligation

    Each party must keep confidential any information obtained from the other in the course of the negotiations for performance on the Service Agreement, as well as the terms of this Service Agreement and the subject matter of this agreement or the transaction provided for in this Agreement (“Confidential Information”). No party may use or disclose the Confidential Information of any other party for an y purpose other than that for which the information was disclosed.

    2. Exclusions

    The obligations of confidence under this Service Agreement do not apply to any information that:

    • Is in the public domain (other than through any breach of this agreement);
    • The receiving party can prove was known to it at the time of disclosure by the disclosing party, free from any obligation of confidence; or
    • A party is required by law to disclose it.

    3. Survival of Obligations

    The obligations of confidentiality under this Agreement survive the expiration or termination of this Agreement.

    4. Permitted Disclosure

    Each party may only disclose another party’s confidential information to those of its employees, contractors or professional advisers who need to know the information and who are aware of the confidential nature of the information.

    5. Destruction of Documents

    On written notice from the owner of any Confidential Information, the recipient of that information will immediately destroy or deliver to the owner all Confidential Information in a recorded form (including any copies of that information) which is in the recipient’s possession or control.

    6. Ownership

    Unless otherwise provided under the Service Agreement, no party will acquire any title to any Confidential Information or other intellectual property of any other party.

    Termination Policy

    Immediate Termination

    A Party may terminate this Agreement at any time with immediate effect by giving notice in writing to another party to this Agreement (the “Defaulting Party”) if:

    a) The Defaulting Party has committed a material breach of this Agreement that is not capable of remedy;

    b) The Defaulting Party has committed a material breach of this Agreement that is capable of remedy and has failed to remedy that breach within fourteen (14) days after receiving notice in writing specifying the breach and requiring its remedy.

    Termination on Notice

    The participant must provide 28 days or 4 weeks written notice to the My Care Plan manager in case of termination.

    Mutual Agreement

    This agreement may be terminated at any time by mutual agreement in writing by all parties to this agreement.

    Consequences of Termination

    Termination of this agreement is without prejudice to any right or cause of action already accrued to a party in respect of any breach of this agreement by another party.

    Feedback, Complaints and Disputes

    If the Participant wishes to give the Provider feedback, the Participant can talk to Palak Chokshi on 0478 630 313 or email on feedback@mcpm.net.au

    If the Participant is not happy with the provision of supports and wishes to make a complaint, the Participant can talk to Palak Chokshi on 0478 630 313 or email on feedback@mcpm.net.au

    If the Participant is not satisfied or does not want to talk to this person, the Participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting ndis.gov.au for further information.

    Goods and Services Tax (GST)

    For the purposes of GST legislation, the Parties confirm that:

    • 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 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 supports are provided; and
    • The participant or their representative will immediately notify My Care Plan Manager if the participant’s NDIS plan is replaced by a new plan or the Participant stops being a participant in the NDIS.

    Terms & Conditions

    • This document as completed by each “Party” forms the agreement between you and us about the supports to be provided to you (or other participants as noted). It is important that you read and understand the entire Contract that sets out the respective rights and obligations of each party.
    • Any advice provided by MCPM outside of financial intermediary advice shall be considered general in nature.
    • MCPM shall not be liable for any failure or delay in the payment of funds or performance of this service agreement if such failure or delay is:
    • Beyond the reasonable control of a party
    • Significantly impacting the ability to fulfill any obligations under this agreement, where such impact could not have been reasonably anticipated or prevented (e.g., Government Acts preventing or hindering any party from fulfilling its obligations under the Service Agreement contract, or prolonged power outages).
    • Nothing in the MCPM service agreement negates or diminishes the statutory guarantees related to the supply of services that the Participant and/or Participant's representative/nominee/guardian are entitled to under Australian Consumer Law (Competition and Consumer Act 2010 - Schedule 2).
    • MCPM assumes in good faith that the information provided by the Participant and/or Participant's representative/nominee/guardian is true and accurate, and that any claims submitted to MCPM accurately reflect the goods and services provided to the Participant in accordance with NDIS guidelines (National Disability Insurance Scheme Act 2013).
    • MCPM does not require clients to fill out a new service agreement for each new NDIS plan they receive. Once signed, this service agreement is enduring and will remain in effect until a formal notice to cease services is provided to MCPM. As the Participant and/or Participant's representative/nominee/guardian, you have the right to terminate the agreement at any time.
    • MCPM will ensure that an annual ‘continuance of service’ notice is presented to the Client to inform them of the anniversary of the service agreement.
    • By submitting the form above, you, as the Participant and/or Participant's representative/nominee/guardian, agree to the information presented in this document.

  • Participant Consent For Use And Disclosure Of Personal Information

  • 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

    • 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.

    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:

  • Share and exchange information Consent Other Third Parties: If there are other people or organisations who have information about you. We also might need to contact them, please list them below, with an address and the details of a person to contact.

  • I give consent for my support plan to be communicated, where appropriate and with my consent, to my support network, other providers and relevant government agencies.

    • I 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.
    • I understand that this consent is valid only for the time specified/enduring.
    • I 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.
    • I 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.
    • I 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.
    • I have been provided with or have been given an opportunity to obtain a copy of Privacy and Confidentiality P&P via client handbook.
    • I give my default consent for my information to be shared with the My Care Plan Manager staff.

    Personal information collection statement

    You may contact us by email, mail or phone using the details provided at the bottom 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 complain 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 withyour consent. We will not disclose your information to commercial companies, however specific service orproduct information as deemed suitable for your management, may be forwarded to you by us, unless youinstruct us not to forward this type of information. Your written consent will be obtained at the start of anynew 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 ensurethat information collected about you is accurate, complete, and up to date. You may have access to yourinformation on request and if you believe that any of the information is inaccurate, we may amend itaccordingly. If you do not provide relevant personal information, in part or in full, this may result in theprovision of incomplete supports or services which may impact on your plans and goals. Any concerns youmay have about this statement or the information we store about you can be directed to our Director.

    NOTE: If the client can’t sign (physical or cognitive reasons) ask a plan nominee/guardians/representative/advocate or ask for their verbalthumbs up to go ahead.

    MUST: Staff must write that consent in the progress notes.

    By signing this Consent Form:

    • I understand I can obtain further information about how the agency handles my personal informationfrom within the Privacy Policy. I can ask for a copy of the document.

    • I understand I have given consent to ask for information about me and share my information withthird parties as listed

    • I understand I can withdraw my consent at any time.

    Pursuant to The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The HealthInformation Protection Act. The purpose of this form is to provide consent to the release of personalinformation to third parties for the purpose of your care and support.

    Conversational: You can ask us any time about what happens to the info we collect. Your privacy willalways be protected cos it’s the law. We only share what you say we can share, unless we think you mightbe in danger. You can change your mind about it at any time, just ask us.

  • Participant Risk Assessment

  • Signature

  • Should be Empty: