NDIA service agreement

Name *

First

Last

Address *

Date of Birth *

NDIS Number *

Contact Number *

Email *

Funding Start Date *

Funding End Date *

Consumable Service Booking Amount

Specify the amount you Mediply Plus to lock in. If no figure given $3000 will be locked in.

Support Coordinator Name

Support Coordinator Contact Number

Support Coordinator Email

Service Agreement *

I will inform the Provider on how I want my funding to be used.
I will notify the provider if any changes happen to my NDIS funding.
I will give 7 days' notice in writing if I want to terminate the agreement.
I will provide adequate information to the the Provider so funds can be claimed.
I am aware that my order will not be processed till fund are claimed by Mediply Plus.
I am aware that I am liable if Mediply Plus cannot claim funds and will cover the gap fee.
I have already created an account .
I authorise for the Provider to make claims on my behalf and agree to the terms and conditions.