Plan Manager 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.

Plan Manager Name *

Plan Manager Contact Number *

Plan Manager Email Address *

The Plan Manager *

Is aware of this service agreement
Is liable for knowingly placing an order that is more than the client's budget or the items ordered are not covered by the cleint's NDIS plan
Is responsible of advising Mediply Plus in writing of any changes to the client's funding
Has gained consent from the client to use and share the information to fulfil orders accordingly
An account has been created for the client.