Parties
This Service Agreement is for a
participant in the National Disability Insurance Scheme (participant), and is
made between:
Current Health Professionals
_
_
Medical History
Current Conditions
Patient Goals
Please use the space below to describe the Patients conditions
Summary
This Service Agreement is made for the purpose of providing therapy services under the participant’s
NDIS plan.
A copy of the participant’s NDIS plan is attached to this Service Agreement
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 disability, and
- enable people with a disability to exercise choice and control in the pursuit of their goals and
the planning and delivery of their supports.
Schedule of supports
The supports and their prices are set out in the attached Schedule of Supports. All prices are GST
inclusive (if applicable) and include the cost of providing the supports.
Responsibilities of the participant/participant’s representative
The participant/participant’s representative agrees to:
- Inform the provider about how they wish the therapy services to be delivered to meet the
participant’s needs
- Treat the provider with courtesy and respect
- Talk to the provider I have any concerns about the therapy services being provided
- Give the provider a minimum of 24 hours’ notice I cannot make a scheduled appointment; and
if the notice is not provided by then, the provider’s cancellation policy will apply
- Give the provider the required notice if I need to end the Service Agreement (see ‘Ending this
Service Agreement’ below for more information), and
- Let the provider know immediately if my NDIS plan is suspended or replaced by a new NDIS
plan or the participant stops being a participant in the NDIS.
- Keep a2z Health Group informed of any changes to my situation that I expect will have an
impact on this Agreement;
- Adhere to a2z Health Group complaint policies and procedure if I have any concerns about
the services or supports being provided; agree if staff are not suitable, I will contact the Client
Service Manager immediately and report my concerns;
- Agree that if I overspend with my NDIA funds, I personally am liable for any extra costs;
- Provide a safe, working environment if working in the family / Participant’s home
Responsibilities of a2z Health Group
a2z Health Group agrees to:
- Review the provision of therapy services at each occasion of service with the participant
- Once agreed, provide therapy services that meet the participant’s needs at the participant’s
preferred times
- Communicate openly and honestly in a timely manner
- Treat the Participant and their family/Carer with courtesy and respect
- Consult the participant on decisions about how treatment is 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
- Keep clear and timely records on the supports provided
- Give the participant a minimum of 24 hours’ notice if the provider has to change a scheduled
appointment to provide therapy services
- 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
- Notify immediately your family/ Carer or other significant stakeholders of any significant
incidents or accidents involving yourself under this Support Service Agreement
- Ensure support is provided to the participant without interruption throughout the period of
their service agreement
- Where changes or interruptions are unavoidable, alternative arrangements are explained and
agreed with the participant
- In the event of worker absence or vacancy, a suitably qualified and/or experienced person will
be allocated to the Participant. This will be documented, communicated and effectively
managed
- Supports are provided based on the least intrusive options, in accordance with contemporary
evidence-informed practices that meet participant needs and help achieve desired outcomes.
Changes to this Service Agreement
If changes to the treatment 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.
Ending this Service Agreement
Should either party wish to end this Service Agreement they must give 1 months’ notice.
If either party seriously breaches this Service Agreement the requirement of notice will be waived.
Payments
Please TICK below
a2z Health Group will seek payment for supports provided to Participants. After checking that a
support was delivered and has been correctly authorised, a claim for payment to NDIA will be made
as soon as practicable. To ensure claims for payments are made in a timely fashion please select an
option from the list below.
The participant has chosen to self-manage the funding for NDIS services provided under this Service
Agreement. After providing those services, the provider will generate an invoice on conclusion of
service provision for the participant to pay. The participant can elect to pay the invoice by cash /
cheque / EFT at the time of consultation.
[OR]
The participant’s Nominee manages the funding for services provided under this Service Agreement.
After providing those services, the provider will send the participant’s Nominee an invoice for those
services for the participant’s Nominee to pay. The participant’s Nominee will pay the invoice by cash
/ cheque / EFT within 7 days.
[OR]
The participant has nominated the NDIA to manage the funding for services provided under this
Service Agreement. After providing those services, the provider will claim payment for those supports
from the NDIA.The participant has nominated the NDIA to manage the funding for services provided under this
Service Agreement. After providing those services, the provider will claim payment for those supports
from the NDIA.
[OR]
The participant has nominated the Plan Management Provider to manage the funding for NDIS
services provided under this Service Agreement. After providing those supports, the provider will
claim payment for those services.
Overdue Accounts
In the event payments for support are not received within 7 days from the issue date of each invoice
the payments will be considered overdue and support for the Participant may not be provided until
such time as the account is sufficiently settled.
Goods and Services Tax (GST)
For the purposes of GST legislation, the Parties confirm that:
- a supply of therapy services 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 therapy
supports are provided; and
- the Participant/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.
Expiration of Support Funding
In the event that your allocated support funds for any of the support items included in your plan are
exhausted prior to your annual review with the NDIA, a2z Health Group will make contact with you
to identify and negotiate alternative arrangements for reimbursement of support costs incurred as
part of your schedule of supports.
Confidentiality
That a2z Health Group and the Participant have a responsibility to:
- Keep all information in this Support Service Agreement confidential.
- Keep all attached information to the Support Service Agreement confidential.
- Only use the confidential information provided to enhance and support its performance in the
provision of agreed services under this Support Service Agreement.
- Provide access to information from this agreement for a specific need allowing the supports
requested to be provided.
Cancellation Policy
Missed appointments will set you back in your recovery, so we ask that wherever possible you keep
all your appointments. If an appointment must be changed, 24 hours notice is appreciated. If less than
24 hours notice is given for a cancellation, a cancellation fee may be charged. Consideration will be
given for unavoidable circumstances. People who repeatedly miss their appointments will have their
plan terminated and NDIA will be notified.
Variations
a2z Health Group reserves the right to vary, replace or terminate this policy from time to time.
Feedback, complaints, and disputes
a2z Health Group is committed to resolving complaints fairly, equitably and as quickly as possible. The complaint can be face to face, by phone, fax, letter or email. The complaint will remain confidential and information will only be available to those who are involved in resolving the complaint.
Complainants will not be disadvantaged or be prevented from continuing to receive supports as a
result of making a complaint.
The Complainant may at any point in the complaints process, contact the following
- Client Service Manager
- CEO
- National Disability Insurance Agency
- An external support agency
If the participant wishes to give the provider feedback, the participant can talk to a representative at
a2z Health Group on 9798-4081 or email:
admin@a2zhealthgroup.com.au
If the participant is not happy with the provision of therapy services and wishes to make a complaint,
the participant can talk to a representative at a2z Health Group.
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.
Included is our complaints policy and procedure, please contact a representative at a2z Health Group
on 9798-4081 or email:
admin@a2zhealthgroup.com.au if you have any further questions.
Independence and Informed Choices
a2z Health Group is committed to assisting Participants in a holistic approach. Each participant is
supported to make informed choices, exercise control and maximise their independence relating to
the supports provided.
- Active decision-making and individual choice is supported for each participant
- Each participant’s right to the dignity of risk in decision-making is supported. When needed,
each participant is supported to make informed choices about the benefits and risks of the
options under consideration
- Each participant has the right to access an advocate (including an independent advocate) of
their choosing, as is their right to have the advocate present
- Each participant has sufficient time to consider and review their options and seek advice if
required
- Each participant has the right to access a2z Health Group Clinic Policies upon request
Contact details
The Participant’s representative can be contacted on:
Plan Manager details (if applicable)
The Provider can be contacted on:
PRIVACY INFORMATION AND CONSENT FORM
PRIVACY INFORMATION
From 21 December 2001 the Privacy Amendment (Private Sector) Act 2000 extended the operation
of the Federal Privacy Act 1988 to include the private health sector throughout Australia. The
principles provide a regulatory framework for the collection, use, storage, security and disclosure of
personal and sensitive information. Individuals have the right to know what information an
organisation holds about them and to have information that is incorrect amended.
a2z Health Group recognises the importance of keeping the personal information that you entrust to
us private and confidential. As a patient of a2z Health Group certain personal information will be
required to establish and maintain your treatment plan, including health information.
Collection of information
This means a2z Health Group will collect information which is necessary to properly assess and treat
you and may include:
- Name, address, telephone numbers, email address
- Date of birth
- Occupation
- Health information (including details of your medical history, family medical history, notes
made during consultations, results of investigations, reports received from other health
providers)
- General practitioner, Support Coordinators, Plan Managers, Advocates and/or other
specialists involved in your care
- NDIS Number
- Transaction details associated with services provided to you by providers at a2z Health Group
- Additional information provided to us by you
- Information provided to use through patient/referrer surveys
This information is collected in order to provide you with the optimum care.
Use of Media
a2z Health Group may photograph, record videos and/or audio clips of you and/or your sessions for
documentation and support purposes. Where appropriate, the photographs/recordings will be
shared with relevant stakeholders (e.g., support coordinators, plan managers,
other health professionals and/or the NDIS) to assist you in gaining access to necessary
therapeutics supports.
PLEASE SELECT whether you do or do not agree to the use of media -
Use and Disclosure
With your consent, a2z Health Group will use and disclose your information for purposes such as:
- Account keeping purposes
- Referral to other medical or health care services
- Quality assurance, practice accreditation and complaint handling
- Advice of treatment options
- To prevent or lessen a serious threat to an individual’s life, health or safety
- Where legally required to do, such as producing records to court
- Providing written or verbal reports to other stakeholders involved in your care to help keep
them informed about your progress
- In the event that you are somehow incapacitated and therefore unable to provide 'informed
consent' in relation to emergency medical care, the person that you nominate as your next of
kin on the ‘NDIS Service Agreement’ will be contacted
Access
You are entitled to access your own health records at any time convenient to both yourself and the
practice. Please contact us if you would like to have access to your records, and we can provide you
with additional information regarding how to do this.
Access can be denied where:
- To provide access would create a serious threat to life or health
- There is a legal impediment to access
- The access should unreasonably impact on the privacy of another
- The request is frivolous
- The information related to anticipated or actual legal proceedings and you would not be
entitled to access the information in those proceedings
- In the interests of National Security
Physiotherapy/Occupational Therapy & Dietetics treatment is generally an effective and safe form
of treatment however like any treatment there are benefits and risks. The purpose of this form is to
let you know what your rights are and how we address the issue of a collaborative decision making
and informed consent between the therapist and patient.
Therapists in this practice will discuss your condition and options for treatment with you so that you
are appropriately informed and can make decisions relating to treatment. You may choose to
consent or refuse any form of treatment for any reason including religious or personal grounds. Once
you have given consent, you may withdraw that consent at any time.
Questions of a Personal Nature.
Your therapist may ask personal questions relating to your injury and how your injury impacts on your
‘activities of daily living’. The more information you provide, the more likely it is that the therapist can
provide effective treatment. It is your choice as to what information you choose to provide. If you feel
uncomfortable with a particular question or group of questions, please let the therapist know and
they will cease.
Physical contact
During the examination, assessment and treatment it may be necessary for your therapist to make
physical contact. Your therapist will ask your permission before making physical contact with you in
any way. Wherever possible, contact will be made using a towel or other forms of screening. Physical
contact requires your express consent. You may withdraw consent at any time at which point, all
physical contact will cease immediately. Please inform your therapist if you feel uncomfortable at any
time.
Children and minors
Consent from a custodial parent is required to treat a minor.
ACKNOWLEDGEMENT AND CONSENT
I provide my consent for a2z Health Group to collect, use and disclose my personal information as
outlined above.
I understand that I am not obliged to provide any information requested of me. I also understand that
failure to provide this medical practice with all the information it needs may restrict the practice's
ability to provide quality of health care and treatment that I require.
I am aware that I have the right to access the information collected about me except in circumstances
where my access might legitimately be withheld. I understand that I will be given an explanation in
these circumstances.
I understand that should my information be required to use for any other purposes other than that
set out above, my consent will be obtained.
I understand I may withdraw my consent as to use and disclosure of my personal information (except
where legal obligations must be met).
I authorise
a2z Health Group to obtain either verbal or written information in relation to my therapy from the following agencies:
- Doctors
- NDIS Representative
- Support Coordinators
- Plan Managers
- Plan Stakeholders
- Other Rehabilitation Health Care providers
- Family Members
- Carers
- Relevant Government agencies
I authorise a2z Health Group to release information concerning relevant aspects of my therapy
program and discuss that information with representatives of the agencies nominated below:
- Doctors
- NDIS Representative
- Support Coordinators
- Plan Managers
- Plan Stakeholders
- Other Rehabilitation Health Care providers
- Family Members
- Carers
- Relevant Government agencies
