Tell us about yourself....

The person completing this form:

I'm an NDIS ParticipantI'm a Parent, Guardian and/or Plan Nominee for a person aged 18 years or overI'm a Parent or Guardian for a person aged under 18 years of age

Your Details - NDIS Participant

First Name

Preferred Name (Optional)

Middle Name

Last Name

Date Of Birth

GenderMaleFemaleOther*

*Other

NDIS Participant Details

First Name

Preferred Name (optional)

Middle Name

Last Name

Date of Birth

GenderMaleFemaleOther*

*Other

Plan Nominee/Authorised Representative

A Plan Nominee/Authorised Representative is someone who is recoginsed/appointed by the NDIA to make decsions on behalf of the NDIS Participant regaridng their NIDS plan and funding.  

First Name

Last Name

Plan Nominee TypeChild Representative (e.g. Parent/Step-Parent/Guardian for a child 18 years of age and under)Plan Nominee (e.g. Guardian for a person 18 years of Age and over)Plan Nominee - Office of Public Guardian

Relationship to Participant Parent – Participant Under 18 years Family MemberGuardianThird-Party legally appointed guardianOther*

Email

Contact Number

MobileHome PhoneWork Phone

You can select more than one option

Mobile Phone

Home Phone

Work Phone

Street Address

Suburb

Post Code

StateQLDNSWVICSAWATASNT

Would you like to provide any further details? (optional)(i.e. custody arrangements/court orders for a child under 18 years of age)

NDIS Plan Details

NDIS Number

Plan Start Date

Plan End Date

Are you transferring from another Plan Manager?

YesNo

Current Plan Manager Name

Exit Date (if known)

Please attach a copy of the NDIS Plan

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Your documents will be held in accordance with our Privacy Policy. If your are unable to attach a copy of your NDIS plan, please email it to: intake@mylinks.com.au

Support Coordinator Details

Do you have a Support Coordinator?

YesNo

Organisation Name

Support Coordinator Name

Support Coordinator Email

Support Coordinator Contact Number

Consent to Share Infromation Disclaimer – By consenting to share information with your Support Coordinator, MyLinks Support Services will provide internal access to your budget and invoices documents. You can remove this access at any time by advising us in writing to: info@mylinks.com.au

Communication Preferences

Do you require and interpreter?Yes No

Do you require any accessibility accommodations? Yes No

I would prefer to be contacted bySMSPhoneEmail

How often would you like to hear from us?I would like a quarterly check-inI will contact the Plan Manager if I need help

Invoices

How would you like us to pay your invoices?

1. I would like MyLinks to pay my invoices automatically2. I would like to approve my invoices before they are submitted to NDIA and paid on your behalf

• This means that we will submit each invoice to the NDIA automatically for claiming on your behalf, whether this is sent from yourself or a provider.

• You can keep up to date with your spend and funding via our APP and we will send you monthly statements so you can see what claims we have paid on your behalf

I would like to approve my invoices by:

Careview APP - You will receive a notification to review and approve an invoiceBy Email - You will receive an email to review and confirm the invoices can be processed

Service Agreement Declaration

I acknowledge that I have read, understood and agree to the Terms and Conditions of this Service Agreement

*

Name

Signature

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Date

I am resposible for the NDIS Plan as an appointed Plan Nominee
I have legal authroity and power to make decsions of behalf of the participant 
I have read and understood the Terms and Conditions of this Service Agreement. *

Plan Nominee/Authorised Representative Name

Signature *

Draw signature|Type signatureClear

Plan Nominee/Authorised Representative

Date

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