NDIS Request for service

Participant Details

NDIS Number *

First Name *

Last Name *

Date of Birth *

Gender

Pronouns

Please provide Participant direct email and phone number.

If the contact information is for a different person, please complete on the following page.

Email Address *

Check Box if partipant does not have an email address

Phone number *

Check Box if partipant does not have a phone number

Residential Address *

Street address *

City *

State *

Postcode *

Living Arrangements *

Lives AloneLives with Family Lives in Supported Accommodation Lives with Other members of the community

Postal Address

Street address

City

State

Postcode

Does the participant require an interpreter? *

Yes No

Language required *

Authorised Representative

Do you have an Authorised Representative? *

YesNo

The Service Agreement will be sent to this person for authorisation.

Please note: AccessHC use DocuSign for all agreement authorisations.

The Service Agreement will be sent to the Participant for authorisation.

Please note: AccessHC use DocuSign for all agreement authorisations.

Please provide an email address.

The Service Agreement will be sent to the Participant for authorisation.

Please note: AccessHC use DocuSign for all agreement authorisations.

Full Name *

Relationship to Participant *

Phone Number *

Email Address *

Emergency Contact

Full Name

Relationship to Participant

Phone Number

Support Coordinator

Do you have a Support Coordinator? *

YesNo

Full Name *

Phone number *

Email Address *

Appointment Contact

Full Name *

Relationship to Participant *

Phone Number *

General Practitioner

Doctor (GP) Name

Phone Number

Clinic Name

Clinic Address

Street address

City

State

Postcode

Privacy and Consent

We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Privacy Act. Our Privacy Policy meets the requirements of all relevant Australian and Victorian Law.

Protecting your Privacy

Click here to view our Privacy Policy

Rights and Responsibilities

Click here to view our Client Rights and Responsibilities

You may collect, use and keep my details to provide Supports.

You may share my details with other providers as needed to provide Supports.

You may share my details with an NDIS approved auditor for NDIS audit purposes.

If we cannot collect and share your details with other providers, we may not be able to properly provide you with Supports. You can choose not to share your details with an auditor now or later. Ask us if you have questions.

Invoicing

Do you agree to endorse us as a "My Provider"? *

YesNo

When you record AccessHC as a provider on your plan, you are letting the NDIA know that AccessHC can make claims against your NDIS plan when we deliver a support to you, this way the NDIA won’t have to check with you before they pay us.

Who manages your NDIS funds? *

Name *

Address

Contact Number

Email Address *

NDIS Plan details

Plan Start Date *

Plan End Date *

Referral Details

The following information needs to be completed with as much detail as possible. This information determines the suitability of the referral to our services. Referrals may be delayed if adequate information is not supplied initially.

Primary Diagnosis *

Secondary DiagnosisPlease complete if relevant to referral

NDIS Plan Goals *

NDIS Plan

Browse

Please upload a copy of your NDIS plan

Service required

Service Required *

Allied Health Mental Health Activity Group

Activity Group *

Mental Health *

Allied Health *

Reason for referral *

Funding *

Improved Daily LivingCapacity BuildingCore Funding

Funds allocated ($) *

Additional Service Required?

Service Required *

Allied Health Mental Health Activity Group

Activity Group *

Mental Health *

Allied Health *

Reason for referral *

Funding *

Improved Daily LivingCapacity BuildingCore Funding

Funds allocated ($) *

Additional Service Required?

Service Required *

Allied Health Mental Health Activity Group

Activity Group *

Mental Health *

Allied Health *

Reason for referral *

Funding *

Improved Daily LivingCapacity BuildingCore Funding

Funds allocated ($) *

Additional Service Required?

Service Required *

Allied Health Mental Health Activity Group

Activity Group *

Mental Health *

Allied Health *

Reason for referral *

Funding *

Improved Daily LivingCapacity BuildingCore Funding

Funds allocated ($) *

Additional Information or Comments

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