NDIS Service Agreement - On The Move OT Pty Ltd
Client first name
*
Client last name
*
Client date of birth
*
Client NDIS number
*
This Service Agreement is for the client noted above and is made with On The Move OT Pty Ltd. The start date of this Service Agreement is the date noted below. The Client and On The Move OT Pty Ltd acknowledge that this Service Agreement ends when either party is notified by the other in writing. 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.
*
I have read and understood the above information
Date
*
Consent to Share Information
I give consent for On The Move OT Pty Ltd staff to share and receive information with the following people for the purposes of helping me achieve my therapeutic goals. I understand I will be given other opportunities to provide verbal consent for On The Move OT Pty Ltd staff to share and receive information from people not listed above for the purposes of helping me achieve my therapeutic goals.
*
Please include the names and contact details for these people.
Photography & Video Consent
On The Move OT Pty Ltd staff may take photos and/or videos to measure the progress you're making towards achieving your goals or to include in clinical documentation, such as reports. NOTE: photos or videos will not be used in marketing/promotional material.
*
I consent to On The Move OT Pty Ltd staff taking photos and/or videos for this purpose.
I do not consent to On The Move OT Pty Ltd staff taking photos and/or videos for this purpose.
Feedback & Complaints
On The Move OT Pty Ltd staff strive to provide exceptional therapeutic services and we are continuously seeking ways to improve. You can contact Chad on 0427 834 680 or chad@onthemoveot.com to provide feedback and complaints in relation to therapeutic services provided by On The Move OT Pty Ltd. You can also contact the NDIS Quality and Safeguard Commission via phone on 1800 035 544 or online at www.ndiscommission.gov.au.
*
I have read and understood the above information
Schedule of Supports
The hourly rate for face-to-face Occupational Therapy services and non-face-to-face Occupational Therapy services (including reporting, travel, sourcing equipment, emails, phone calls and team collaboration etc) is $193.99. In the event of an NDIS benchmark price change, our hourly rate may also change. You'll be provided with notice as detailed in the Service Agreement.
Please tick relevant services you wish to receive from us. By ticking these services and signing this Service Agreement, you agree with the quoted amounts for each service
*
Occupational Therapy Driver Assessment & Report | 8 to 10 hours
Occupational Therapy Driver Assessment & Report (Review) | 5 to 6 hours
Occupational Therapy Program - Driving/Cognitive Specific | 15 hours
Occupational Therapy Program - Driving Simulator Therapy | 8 hours
Vehicle Modifications under $15,000| 5 to 6 hours
Vehicle Modifications over $15,000| 10 to 15 hours
Occupational Therapy Assessment & Report - Functional | 12 to 15 hours
Brief Occupational Therapy Review Report (required prior to the next scheduled NDIA Plan review) | 2.5 hours
Minor Home Modification Assessment & Supporting Letter | 4 to 8 hours for each minor home modification
Follow up review and training in the use of completed minor home modifications | 2 to 4 hours
Assistive Technology Assessment, Trial & Supporting Letter for items under $15,000 (excluding wheelchairs and motorised scooters) | 5 hours for each item
Assistive Technology Assessment, Trial & Supporting Letter for wheelchairs under $15,000| 8 to 10 hours
Assistive Technology Assessment, Trial & Supporting Letter for mobility scooters under $15,000 | 8 to 10 hours
Assistive Technology Assessment, Trial & Report for items over $15,000 | 10 hours per item
Follow-up review and training in the use of an assistive technology item after delivery | 2 to 4 hours
Occupational Therapy Program | 10 hours
Occupational Therapy Program | 15 hours
Occupational Therapy Program | 20 hours
Occupational Therapy Program | 25 hours
Provider travel – non labour costs’ will be charged in addition to the amounts noted above. This includes the cost of TOLLS, public transport fares and parking tickets incurred while delivering supports for you. It also includes $0.85 for every kilometre travelled while delivering supports to you. If you are having an Occupational Therapy Driver Assessment with us, the cost of the Driving Instructor used for the assessment will also be charged in addition to this amount (usually between $110 to $140).
Agreements
On The Move OT Pty Ltd staff commit to: • Consult you on decisions about how we provide therapeutic supports for you. • Establish a written plan detailing the nature and price of therapeutic supports to be provided for you (this is called a ‘Schedule of Supports’). • Provide Occupational Therapy services according to the Schedule of Supports. We will consult you and provide you with a new Schedule of Supports if we both agree a change is required to help you achieve your funded goals. • Claim or invoice for all agreed upon services we provide for you and issue statements of the claims or invoices if you request these. • Provide at least 7 days’ notice in the event of a price rise. Our prices align with current NDIS benchmark rates. • Treat you with respect and courtesy. • Seek your consent to share information, unless permitted by relevant legislation to share without consent.
*
I have read and understood that above information
By signing this document, you (Client) agree to and acknowledge: • Your NDIS Plan is expected to remain in effect during the period supports are provided for you by On The Move OT Pty Ltd. You are required to let On The Move OT Pty Ltd staff know immediately if your NDIS Plan is no longer current. • You are responsible for the payment for all therapeutic services provided for you by On The Move OT Pty Ltd staff. You agree to ensure there are sufficient funds to pay for these supports. • On The Move OT Pty Ltd prices align with the current NDIS benchmark rates. You can access these rates on our website - www.onthemoveot.com. You agree to our fees (including provide travel and non-labour related travel costs). • On The Move OT Pty Ltd has a cancellation policy in alignment with the current NDIS Price Guide and you can access this on our website - www.onthemoveot.com. You agree to our cancellation policy. • On The Move OT Pty Ltd will give the National Disability Insurance Agency (NDIS) access to all accounts and records requested by them, in accordance with relevant legislation. • You will work collaboratively with On The Move OT Pty Ltd to achieve your funded goals. • You will treat On The Move OT Pty Ltd staff with courtesy and respect. • On The Move OT Pty Ltd staff are unable to provide services for you while you (or anyone present during an appointment with our staff) are under the influence of alcohol or illicit substances at the time of appointment. Failure to comply with this will result in the appointment being cancelled and a cancellation fee being charged. • On The Move OT Pty Ltd staff are unable to provide face-to-face services for you if you (or anyone present during an appointment with our staff) smoke cigarettes during the appointment. This includes smoking cigarettes inside and outside of the location of the appointment. Failure to comply with this will result in the appointment being cancelled and a cancellation fee being charged. • On The Move OT Pty Ltd staff need to be notified in advance of who will be present during face-to-face appointments with you.
*
I have read and understood the above information.
Payments
On The Move OT Pty Ltd will seek payment for the provision of supports. Supports will only be provided if invoices have been paid on time. If the client has outstanding invoices, supports will be cancelled and may only resume when outstanding invoices have been paid.
*
SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. On The Move OT Pty Ltd will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by direct debit / EFT within 7 days. If an invoice is paid after the invoice due date services will cease and may only resume upon full payment of outstanding invoices. Subsequent services may need to be paid in advance of the service having been provided.
PLAN MANAGED - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. On The Move OT Pty Ltd will claim payment for those supports from the Plan Manager. It is the responsibility of the client / client representative to ensure their Plan Manager can pay invoices within 7 days of the invoice being issued.
Signature of Client / Client Nominee
*
Draw signature
|
Type signature
Clear
Full name of the person signing this form
*
Date signed
*
Email of the person signing this form
*
Please wait, files are uploading..
Submit
