United Abilities NDIS SERVICE AGREEMENT Spam protection, skip this field Please be assured that the information you provide on this form is confidential and only available to United Abilities. This service agreement is made between the National Disability Insurance Scheme (NDIS) Participant or Participant’s representative and United Abilities, registered NDIS provider. This agreement will remain in force until a new service agreement is entered into, or either party advises in writing that this agreement has come to an end. First Name Last Name Date Of Birth MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040 Address Phone Number 🇦🇺 +61🇦🇨 Ascension Island +247🇦🇩 Andorra +376🇦🇪 United Arab Emirates +971🇦🇫 Afghanistan +93🇦🇬 Antigua And Barbuda +1🇦🇮 Anguilla +1🇦🇱 Albania +355🇦🇲 Armenia +374🇦🇴 Angola +244🇦🇷 Argentina +54🇦🇸 American Samoa +1🇦🇹 Austria +43🇦🇺 Australia +61🇦🇼 Aruba +297🇦🇽 Åland Islands +358🇦🇿 Azerbaijan +994🇧🇦 Bosnia And Herzegovina +387🇧🇧 Barbados +1🇧🇩 Bangladesh +880🇧🇪 Belgium +32🇧🇫 Burkina Faso +226🇧🇬 Bulgaria +359🇧🇭 Bahrain +973🇧🇮 Burundi +257🇧🇯 Benin +229🇧🇱 Saint Barthélemy +590🇧🇲 Bermuda +1🇧🇳 Brunei Darussalam +673🇧🇴 Bolivia +591🇧🇶 Bonaire, Sint Eustatius And Saba +599🇧🇷 Brazil +55🇧🇸 Bahamas +1🇧🇹 Bhutan +975🇧🇼 Botswana +267🇧🇾 Belarus +375🇧🇿 Belize +501🇨🇦 Canada +1🇨🇨 Cocos (keeling) Islands +61🇨🇩 Congo, The Democratic Republic Of The +243🇨🇫 Central African Republic +236🇨🇬 Congo +242🇨🇭 Switzerland +41🇨🇮 Cote D'ivoire +225🇨🇰 Cook Islands +682🇨🇱 Chile +56🇨🇲 Cameroon +237🇨🇳 China +86🇨🇴 Colombia +57🇨🇷 Costa Rica +506🇨🇺 Cuba +53🇨🇻 Cape Verde +238🇨🇼 Curaçao +599🇨🇽 Christmas Island +61🇨🇾 Cyprus +357🇨🇿 Czech Republic +420🇩🇪 Germany +49🇩🇯 Djibouti +253🇩🇰 Denmark +45🇩🇲 Dominica +1🇩🇴 Dominican Republic +1🇩🇿 Algeria +213🇪🇨 Ecuador +593🇪🇪 Estonia +372🇪🇬 Egypt +20🇪🇭 Western Sahara +212🇪🇷 Eritrea +291🇪🇸 Spain +34🇪🇹 Ethiopia +251🇫🇮 Finland +358🇫🇯 Fiji +679🇫🇰 Falkland Islands (malvinas) +500🇫🇲 Micronesia, Federated States Of +691🇫🇴 Faroe Islands +298🇫🇷 France +33🇬🇦 Gabon +241🇬🇧 United Kingdom +44🇬🇩 Grenada +1🇬🇪 Georgia +995🇬🇫 French Guiana +594🇬🇬 Guernsey +44🇬🇭 Ghana +233🇬🇮 Gibraltar +350🇬🇱 Greenland +299🇬🇲 Gambia +220🇬🇳 Guinea +224🇬🇵 Guadeloupe +590🇬🇶 Equatorial Guinea +240🇬🇷 Greece +30🇬🇹 Guatemala +502🇬🇺 Guam +1🇬🇼 Guinea-bissau +245🇬🇾 Guyana +592🇭🇰 Hong Kong +852🇭🇳 Honduras +504🇭🇷 Croatia +385🇭🇹 Haiti +509🇭🇺 Hungary +36🇮🇩 Indonesia +62🇮🇪 Ireland +353🇮🇱 Israel +972🇮🇲 Isle Of Man +44🇮🇳 India +91🇮🇴 British Indian Ocean Territory +246🇮🇶 Iraq +964🇮🇷 Iran, Islamic Republic Of +98🇮🇸 Iceland +354🇮🇹 Italy +39🇯🇪 Jersey +44🇯🇲 Jamaica +1🇯🇴 Jordan +962🇯🇵 Japan +81🇰🇪 Kenya +254🇰🇬 Kyrgyzstan +996🇰🇭 Cambodia +855🇰🇮 Kiribati +686🇰🇲 Comoros +269🇰🇳 Saint Kitts And Nevis +1🇰🇵 North Korea +850🇰🇷 South Korea +82🇰🇼 Kuwait +965🇰🇾 Cayman Islands +1🇰🇿 Kazakhstan +7🇱🇦 Lao People's Democratic Republic +856🇱🇧 Lebanon +961🇱🇨 Saint Lucia +1🇱🇮 Liechtenstein +423🇱🇰 Sri Lanka +94🇱🇷 Liberia +231🇱🇸 Lesotho +266🇱🇹 Lithuania +370🇱🇺 Luxembourg +352🇱🇻 Latvia +371🇱🇾 Libya +218🇲🇦 Morocco +212🇲🇨 Monaco +377🇲🇩 Moldova, Republic Of +373🇲🇪 Montenegro +382🇲🇫 Saint Martin (french Part) +590🇲🇬 Madagascar +261🇲🇭 Marshall Islands +692🇲🇰 North Macedonia, Republic Of +389🇲🇱 Mali +223🇲🇲 Myanmar +95🇲🇳 Mongolia +976🇲🇴 Macao +853🇲🇵 Northern Mariana Islands +1🇲🇶 Martinique +596🇲🇷 Mauritania +222🇲🇸 Montserrat +1🇲🇹 Malta +356🇲🇺 Mauritius +230🇲🇻 Maldives +960🇲🇼 Malawi +265🇲🇽 Mexico +52🇲🇾 Malaysia +60🇲🇿 Mozambique +258🇳🇦 Namibia +264🇳🇨 New Caledonia +687🇳🇪 Niger +227🇳🇫 Norfolk Island +672🇳🇬 Nigeria +234🇳🇮 Nicaragua +505🇳🇱 Netherlands +31🇳🇴 Norway +47🇳🇵 Nepal +977🇳🇷 Nauru +674🇳🇺 Niue +683🇳🇿 New Zealand +64🇴🇲 Oman +968🇵🇦 Panama +507🇵🇪 Peru +51🇵🇫 French Polynesia +689🇵🇬 Papua New Guinea +675🇵🇭 Philippines +63🇵🇰 Pakistan +92🇵🇱 Poland +48🇵🇲 Saint Pierre And Miquelon +508🇵🇷 Puerto Rico +1🇵🇸 Palestinian Territory, Occupied +970🇵🇹 Portugal +351🇵🇼 Palau +680🇵🇾 Paraguay +595🇶🇦 Qatar +974🇷🇪 Reunion +262🇷🇴 Romania +40🇷🇸 Serbia +381🇷🇺 Russian Federation +7🇷🇼 Rwanda +250🇸🇦 Saudi Arabia +966🇸🇧 Solomon Islands +677🇸🇨 Seychelles +248🇸🇩 Sudan +249🇸🇪 Sweden +46🇸🇬 Singapore +65🇸🇭 Saint Helena +290🇸🇮 Slovenia +386🇸🇯 Svalbard And Jan Mayen +47🇸🇰 Slovakia +421🇸🇱 Sierra Leone +232🇸🇲 San Marino +378🇸🇳 Senegal +221🇸🇴 Somalia +252🇸🇷 Suriname +597🇸🇸 South Sudan +211🇸🇹 Sao Tome And Principe +239🇸🇻 El Salvador +503🇸🇽 Sint Maarten (dutch Part) +1🇸🇾 Syrian Arab Republic +963🇸🇿 Eswatini +268🇹🇦 Saint Helena +290🇹🇨 Turks And Caicos Islands +1🇹🇩 Chad +235🇹🇬 Togo +228🇹🇭 Thailand +66🇹🇯 Tajikistan +992🇹🇰 Tokelau +690🇹🇱 Timor-leste +670🇹🇲 Turkmenistan +993🇹🇳 Tunisia +216🇹🇴 Tonga +676🇹🇷 Turkey +90🇹🇹 Trinidad And Tobago +1🇹🇻 Tuvalu +688🇹🇼 Taiwan +886🇹🇿 Tanzania, United Republic Of +255🇺🇦 Ukraine +380🇺🇬 Uganda +256🇺🇸 United States Of America +1🇺🇾 Uruguay +598🇺🇿 Uzbekistan +998🇻🇦 Holy See (vatican City State) +39🇻🇨 Saint Vincent And The Grenadines +1🇻🇪 Venezuela +58🇻🇬 Virgin Islands, British +1🇻🇮 Virgin Islands, U.s. +1🇻🇳 Vietnam +84🇻🇺 Vanuatu +678🇼🇫 Wallis And Futuna +681🇼🇸 Samoa +685🇽🇰 Kosovo +383🇾🇪 Yemen +967🇾🇹 Mayotte +262🇿🇦 South Africa +27🇿🇲 Zambia +260🇿🇼 Zimbabwe +263 Email NDIS Number (optional) 9 digits. NDIS Plan Start Date (optional) MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040 NDIS Plan End Date (optional) MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040PARTICIPANT'S REPRESENTATIVE First Name (optional) Last Name (optional) Relationship To Participant (optional) Phone Number (optional) 🇦🇺 +61🇦🇨 Ascension Island +247🇦🇩 Andorra +376🇦🇪 United Arab Emirates +971🇦🇫 Afghanistan +93🇦🇬 Antigua And Barbuda +1🇦🇮 Anguilla +1🇦🇱 Albania +355🇦🇲 Armenia +374🇦🇴 Angola +244🇦🇷 Argentina +54🇦🇸 American Samoa +1🇦🇹 Austria +43🇦🇺 Australia +61🇦🇼 Aruba +297🇦🇽 Åland Islands +358🇦🇿 Azerbaijan +994🇧🇦 Bosnia And Herzegovina +387🇧🇧 Barbados +1🇧🇩 Bangladesh +880🇧🇪 Belgium +32🇧🇫 Burkina Faso +226🇧🇬 Bulgaria +359🇧🇭 Bahrain +973🇧🇮 Burundi +257🇧🇯 Benin +229🇧🇱 Saint Barthélemy +590🇧🇲 Bermuda +1🇧🇳 Brunei Darussalam +673🇧🇴 Bolivia +591🇧🇶 Bonaire, Sint Eustatius And Saba +599🇧🇷 Brazil +55🇧🇸 Bahamas +1🇧🇹 Bhutan +975🇧🇼 Botswana +267🇧🇾 Belarus +375🇧🇿 Belize +501🇨🇦 Canada +1🇨🇨 Cocos (keeling) Islands +61🇨🇩 Congo, The Democratic Republic Of The +243🇨🇫 Central African Republic +236🇨🇬 Congo +242🇨🇭 Switzerland +41🇨🇮 Cote D'ivoire +225🇨🇰 Cook Islands +682🇨🇱 Chile +56🇨🇲 Cameroon +237🇨🇳 China +86🇨🇴 Colombia +57🇨🇷 Costa Rica +506🇨🇺 Cuba +53🇨🇻 Cape Verde +238🇨🇼 Curaçao +599🇨🇽 Christmas Island +61🇨🇾 Cyprus +357🇨🇿 Czech Republic +420🇩🇪 Germany +49🇩🇯 Djibouti +253🇩🇰 Denmark +45🇩🇲 Dominica +1🇩🇴 Dominican Republic +1🇩🇿 Algeria +213🇪🇨 Ecuador +593🇪🇪 Estonia +372🇪🇬 Egypt +20🇪🇭 Western Sahara +212🇪🇷 Eritrea +291🇪🇸 Spain +34🇪🇹 Ethiopia +251🇫🇮 Finland +358🇫🇯 Fiji +679🇫🇰 Falkland Islands (malvinas) +500🇫🇲 Micronesia, Federated States Of +691🇫🇴 Faroe Islands +298🇫🇷 France +33🇬🇦 Gabon +241🇬🇧 United Kingdom +44🇬🇩 Grenada +1🇬🇪 Georgia +995🇬🇫 French Guiana +594🇬🇬 Guernsey +44🇬🇭 Ghana +233🇬🇮 Gibraltar +350🇬🇱 Greenland +299🇬🇲 Gambia +220🇬🇳 Guinea +224🇬🇵 Guadeloupe +590🇬🇶 Equatorial Guinea +240🇬🇷 Greece +30🇬🇹 Guatemala +502🇬🇺 Guam +1🇬🇼 Guinea-bissau +245🇬🇾 Guyana +592🇭🇰 Hong Kong +852🇭🇳 Honduras +504🇭🇷 Croatia +385🇭🇹 Haiti +509🇭🇺 Hungary +36🇮🇩 Indonesia +62🇮🇪 Ireland +353🇮🇱 Israel +972🇮🇲 Isle Of Man +44🇮🇳 India +91🇮🇴 British Indian Ocean Territory +246🇮🇶 Iraq +964🇮🇷 Iran, Islamic Republic Of +98🇮🇸 Iceland +354🇮🇹 Italy +39🇯🇪 Jersey +44🇯🇲 Jamaica +1🇯🇴 Jordan +962🇯🇵 Japan +81🇰🇪 Kenya +254🇰🇬 Kyrgyzstan +996🇰🇭 Cambodia +855🇰🇮 Kiribati +686🇰🇲 Comoros +269🇰🇳 Saint Kitts And Nevis +1🇰🇵 North Korea +850🇰🇷 South Korea +82🇰🇼 Kuwait +965🇰🇾 Cayman Islands +1🇰🇿 Kazakhstan +7🇱🇦 Lao People's Democratic Republic +856🇱🇧 Lebanon +961🇱🇨 Saint Lucia +1🇱🇮 Liechtenstein +423🇱🇰 Sri Lanka +94🇱🇷 Liberia +231🇱🇸 Lesotho +266🇱🇹 Lithuania +370🇱🇺 Luxembourg +352🇱🇻 Latvia +371🇱🇾 Libya +218🇲🇦 Morocco +212🇲🇨 Monaco +377🇲🇩 Moldova, Republic Of +373🇲🇪 Montenegro +382🇲🇫 Saint Martin (french Part) +590🇲🇬 Madagascar +261🇲🇭 Marshall Islands +692🇲🇰 North Macedonia, Republic Of +389🇲🇱 Mali +223🇲🇲 Myanmar +95🇲🇳 Mongolia +976🇲🇴 Macao +853🇲🇵 Northern Mariana Islands +1🇲🇶 Martinique +596🇲🇷 Mauritania +222🇲🇸 Montserrat +1🇲🇹 Malta +356🇲🇺 Mauritius +230🇲🇻 Maldives +960🇲🇼 Malawi +265🇲🇽 Mexico +52🇲🇾 Malaysia +60🇲🇿 Mozambique +258🇳🇦 Namibia +264🇳🇨 New Caledonia +687🇳🇪 Niger +227🇳🇫 Norfolk Island +672🇳🇬 Nigeria +234🇳🇮 Nicaragua +505🇳🇱 Netherlands +31🇳🇴 Norway +47🇳🇵 Nepal +977🇳🇷 Nauru +674🇳🇺 Niue +683🇳🇿 New Zealand +64🇴🇲 Oman +968🇵🇦 Panama +507🇵🇪 Peru +51🇵🇫 French Polynesia +689🇵🇬 Papua New Guinea +675🇵🇭 Philippines +63🇵🇰 Pakistan +92🇵🇱 Poland +48🇵🇲 Saint Pierre And Miquelon +508🇵🇷 Puerto Rico +1🇵🇸 Palestinian Territory, Occupied +970🇵🇹 Portugal +351🇵🇼 Palau +680🇵🇾 Paraguay +595🇶🇦 Qatar +974🇷🇪 Reunion +262🇷🇴 Romania +40🇷🇸 Serbia +381🇷🇺 Russian Federation +7🇷🇼 Rwanda +250🇸🇦 Saudi Arabia +966🇸🇧 Solomon Islands +677🇸🇨 Seychelles +248🇸🇩 Sudan +249🇸🇪 Sweden +46🇸🇬 Singapore +65🇸🇭 Saint Helena +290🇸🇮 Slovenia +386🇸🇯 Svalbard And Jan Mayen +47🇸🇰 Slovakia +421🇸🇱 Sierra Leone +232🇸🇲 San Marino +378🇸🇳 Senegal +221🇸🇴 Somalia +252🇸🇷 Suriname +597🇸🇸 South Sudan +211🇸🇹 Sao Tome And Principe +239🇸🇻 El Salvador +503🇸🇽 Sint Maarten (dutch Part) +1🇸🇾 Syrian Arab Republic +963🇸🇿 Eswatini +268🇹🇦 Saint Helena +290🇹🇨 Turks And Caicos Islands +1🇹🇩 Chad +235🇹🇬 Togo +228🇹🇭 Thailand +66🇹🇯 Tajikistan +992🇹🇰 Tokelau +690🇹🇱 Timor-leste +670🇹🇲 Turkmenistan +993🇹🇳 Tunisia +216🇹🇴 Tonga +676🇹🇷 Turkey +90🇹🇹 Trinidad And Tobago +1🇹🇻 Tuvalu +688🇹🇼 Taiwan +886🇹🇿 Tanzania, United Republic Of +255🇺🇦 Ukraine +380🇺🇬 Uganda +256🇺🇸 United States Of America +1🇺🇾 Uruguay +598🇺🇿 Uzbekistan +998🇻🇦 Holy See (vatican City State) +39🇻🇨 Saint Vincent And The Grenadines +1🇻🇪 Venezuela +58🇻🇬 Virgin Islands, British +1🇻🇮 Virgin Islands, U.s. +1🇻🇳 Vietnam +84🇻🇺 Vanuatu +678🇼🇫 Wallis And Futuna +681🇼🇸 Samoa +685🇽🇰 Kosovo +383🇾🇪 Yemen +967🇾🇹 Mayotte +262🇿🇦 South Africa +27🇿🇲 Zambia +260🇿🇼 Zimbabwe +263 Email (optional) The NDIS And This Service AgreementThis Service Agreement is made for the purpose of providing support under the Participant’s National Disability Insurance Scheme (NDIS) plan.The Parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:support the independence and social and economic participation of people with a disability, andEnable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of support. Plan Type Plan Managed Agency Managed Self Managed If the Plan Type is Plan Managed, we need to know who the plan manager is. My Plan Manager Is: Weekly Support. The amount of hours can vary from week to week. This is just an estimate of expected services provided. How many hours from Monday-Friday do you need support? (Weekly) (optional) NDIS Item 01_011_0107_1_1 $55 How many hours on a Saturday do you need support? (Weekly) (optional) NDIS 01_013_0107_1_1 $77 How many hours on a Sunday do you need support? (Weekly) (optional) NDIS 01_014_0107_1_1 $100 How many hours on a Public Holiday do you need support? (Weekly) (optional) NDIS 01_012_0107_1_1 $120 How many weekly group activities would like to attend? (Weekly) (optional) NDIS 04_170_0136_6_1 $25 (Bowling, Yoga, Soccer, Basketball, etc)NDIS Price Structure. All prices are GST inclusive (if applicable) and include the cost of providing support.Additional expenses (i.e. things 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, event tickets, meals, etc.Responsibilities of the Provider.The Provider agrees to review the provision of support at least every twelve month with the Participant once agreed, provide supports that meet the Participant’s needs at the Participant’s preferred times, communicate openly and honestly in a timely manner, treat the Participant with courtesy and respect, consult the Participant on decisions about how supports are provided, give the Participant information about managing any complaints or disagreements and details of the provider’s cancellation policy (if relevant), listen to the Participant’s feedback and resolve problems quickly, give the Participant a minimum of 48 hours’ notice if the Provider has to change a scheduled appointment to provide support, give the Participant the required notice if the Provider needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information) protect the Participant’s privacy and confidential information, provide support in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law; keep accurate records on the supports provided to the Participant, and issue regular invoices and statements of the supports delivered to the Participant.Responsibilities of the Participant. The participant / participant’s representative agrees to inform the Provider about how they wish the supports to be delivered to meet the Participant’s needs, talk to the Provider if the Participant has any concerns about support being provided, give the Provider a minimum of 48 hours’ notice if the Participant cannot make a scheduled appointment; and if the notice is not provided by then, the Provider will charge for the scheduled appointment, give the Provider the required notice if the Participant needs to end the Service Agreement (see ‘Ending this Service Agreement’ below for more information), andLet the Provider know 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.Media Release I give permission for United Abilities to use my image for promotional purposes. Yes No Privacy ConsentUnder the Information Sharing Guideline your informed consent for the sharing of information will be sought and respected in all situations unless:1. it is unreasonable or impractible to gain consent or consent has been refused and2. without information being shared, it is anticipated a child, vulnerable person or member of their family will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public safety.Terms and Conditions. If changes to the supports or their 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. Should either Party wish to end this Service Agreement they must give 2 weeks notice. If either Party seriously breaches this Service Agreement the requirement of notice will be waived. If the Participant wishes to give the Provider feedback or complaints, the Participant can talk to us on (08) 8117 4465. If the Participant is not satisfied or does not want to talk to the provider, 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. For the purposes of GST legislation, the Parties confirm that a supply of support 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 Participant’s representative will immediately notify the Provider if the Participant’s NDIS Plan is replaced by a new plan or the Participant stops being a participant in the NDIS. I understand and agree to the terms and conditions outlined in this document. I agree to the terms and conditions I agree to United Abilities eSign policy. Signature I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law Save draft