Registration Pack Request for ServicesThank you for choosing Interactive Plan Management as your preferred provider for plan management services. Please complete the registration form below and attach a copy of you current NDIS plan if you have it available. Once you submit the forms, you will receive an email with a copy of the completed registration form attached. One of our plan managers will contact you within two business days. Participant DetailsParticipant NDIS Number* Title*MrMrsMsMissMasterName* First Last Phone* Date of Birth* DD slash MM slash YYYY Email* Home Address* Street Address Address Line 2 Suburb State Postcode Postal Address (if different to above) Street Address Address Line 2 Suburb State Postcode Consent* I acknowledge that the information on this form will be used by Interactive Plan Management to begin the setup process for plan management services of my NDIS plan.Signature of Participant/nominated representative*Name of Participant/nominated representative* Consent to Share InformationInteractive Plan Management complies with relevant privacy legislation and in the standards set for dealing with personal information outlined in our Policy, Practice Guidelines and Procedures. Interactive Plan Management will work closely with other agencies to provide you with quality plan management services. Your informed consent for the sharing of information will be sought and respected in all situations unless: we are obliged by law to disclose your information regardless of consent or otherwise it is unsafe or impossible to gain consent or consent has been refused, and without information being shared, it is anticipated a child, young person or adult will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public health or safety. Primary Purpose Consent* Yes, the primary purpose(s) of this service has been explained to me and I consent to the sharing of my personal information to assist in achieving the primary purpose(s). Proposed Use and Disclosure of my personal information Interactive Plan Management may share information with the following service providers in order to provide the best possible plan management services. Service Provider #1Service Type Name of Agency Type of Information Including limits as applicable. e.g. invoices, budgets, statements, payments, service agreements, etc.Service Provider #2Service Type Name of Agency Type of Information Including limits as applicable. e.g. invoices, budgets, statements, payments, service agreements, etc.Service Provider #3Service Type Name of Agency Type of Information Including limits as applicable. e.g. invoices, budgets, statements, payments, service agreements, etc.Service Provider #4Service Type Name of Agency Type of Information Including limits as applicable. e.g. invoices, budgets, statements, payments, service agreements, etc.Service Provider #5Service Type Name of Agency Type of Information Including limits as applicable. e.g. invoices, budgets, statements, payments, service agreements, etc.Interactive Plan Management offers a premium service to manage your plan and budget more effectively. To achieve this, we require access to your NDIS plan and Service Agreement(s). Please tick the box only if you agree to us accessing this information.* Yes, I agree to Interactive Plan Management accessing my NDIS plan through the myplace provider portal to reconcile records and issue statements to me / my nominee on a regular basis. (this includes a hard copy or PDF version if available).By allowing Interactive Plan Management access to service agreements that you have signed with your service provider(s), IPM are able to more effectively manage funding for those services that you have agreed to. We can alert you if spending for service providers is exceeding your agreement.* Yes, I agree to Interactive Plan Management accessing my current Service Agreements.Record of Client Consent* Written Client Consent Verbal Consent My worker has discussed with me how and why certain information about me may need to be provided to other service providers. I understand the recommendations and I give my permission for the information to be shared as detailed above.Signature*Signed by* Client Authorised Representative Workers Use Only Verbal consent should only be used where it is not practicable to obtain written consent. I have discussed the proposed referrals with the client or authorised representative and I am satisfied that they understand the proposed uses and disclosures and have provided their informed consent to these.Name (Worker)* Position* Signature*To ensure you make an informed decision about consent to the disclosure of your information, please review and tick the boxes for the following: *1. Your information will only be released if you have provided consent. You understand that services will still be provided even if you do not want information disclosed.* Yes2. Information will only be shared without consent if there is a serious threat to your health or safety, to report illegal activity or if the information is required under law.* Yes3. I can access the privacy brochure from IPM’s website.* YesService AgreementParties: This Service Agreement is between Interactive Plan Management Pty Ltd and the Participant/nominated representative in the National Disability Insurance Scheme.The Service Agreement will be in effect from today for the duration of the Participants association with Interactive Plan Management, or until we are notified in writing by the Participant/nominated representative to end this Service Agreement. Upon acceptance of this Service Agreement, the Participant/nominated representative will provide a copy of their NDIS plan to Interactive Plan Management. Schedule of Supports: Interactive Plan Management agrees to provide to the Participant the services of plan management. The supports and their prices are set out in the Schedule of Supports below. All pricing is GST inclusive (if applicable) and includes the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a Participants NDIS supports) are the responsibility of the Participant/nominated representative and are not included in the cost of the supports. Responsibilities of Provider: Interactive Plan Management agrees to; Provide plan management services Reconcile client balances (when consent is given to access MyPlace provider portal) Pay supplier invoices on behalf of clients & Process client reimbursement claims Track expenditure against client budget Provide regular statements of expenditure and available funding upon request Assist with purchases where appropriate Troubleshooting Client liaison – email, phone etc Consult the Participant/nominated representative on request, regarding decisions about how funds are spent Communicate openly and honestly in a timely manner Treat the participant/nominated representative with courtesy and respect Listen to the Participant/nominated representative’s feedback and resolve problems quickly Protect the Participant’s privacy and confidential information as per Interactive Plan Management Privacy Policy Responsibilities of Participant/nominated representative: I agree to: Take due steps to provide information as requested to Interactive Plan Management in a timely manner Treat Interactive Plan Management staff with courtesy and respect Discuss any concerns about our service with Interactive Plan Management Advise Interactive Plan Management immediately if the Participants NDIS plan is suspended or replaced by a new NDIS plan, or the Participant stops being a participant in the NDIS. Payments Interactive Plan Management will claim directly from the NDIS an agreed monthly fee for the provision of support as agreed in Schedule of Supports. By nominating Interactive Plan Management to provide plan management services and manage the funding, we will claim from the NDIA portal for funding up to the amounts specified in the support category and budget approved in the Participant’s current NDIS plan. After these supports are delivered, the service provider or Participant/nominated representative will claim payment for those supports from Interactive Plan Management by forwarding an invoice to: accounts@interactiveplanmanagement.com.au Changes to this Service Agreement: If changes are required to be made to this Service Agreement, 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 both Parties. Ending this Service Agreement: Should either party wish to terminate this Service Agreement they must give two weeks notice in writing. If either Party seriously breaches this Service Agreement the requirement of notification will be waived. Feedback, Complaints and Disputes: If the Participant/nominated representative wishes to provide feedback, or is not satisfied with the provision of supports and wishes to make a complaint, the Participant/nominated representative can contact Danielle Mathie at Interactive Plan Management on 0434 619 017 or email admin@interactiveplanmanagement.com.au two weeks notice in writing. Goods and Services Tax (GST): For the purposes of GST legislation, the Parties confirm that: A supply of supports 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 Participants NDIS plan currently in effect under section 37 of the NDIS Act; Interactive Plan Management will pay GST as per specified in the National Disability Insurance Scheme Act 2013 (NDIS Act). Banking Details: The Participant/nominee representative will provide bank details, if necessary, to Interactive Plan Management for reimbursement.Schedule of Supports – Improved Life Choices: Support Description of Support Price and Payment Information Plan Management and Financial Capacity Building -Set up Costs (14_033_0127_8_3) Setting up client details into our client management systemSetting up client account within our finance systemSetting up service and budget allocation $232.35Set-up fee Plan Management – Financial Administration (14_034_0127_8_3) Reconciling client balancesPaying supplier invoices on behalf of the clientProcessing client reimbursement claimsTracking expenditure against client budgetMonthly statements of expenditure and available funding Assisting with purchasingTroubleshootingClient Liaison – emails, phone calls etc $104.45 per month x 12 = $1,253.40 TOTAL $1,485.75 Plan and Financial Capacity Building (14_031_0127_8_3) Undertaking regular liaison with participant to strengthen their ability to undertake tasks associated with the management of their supports. Please note: not all participants have this funding available in their plan. $61.76 per hour Please note any changes will be in accordance with the NDIA pricing guide. Contact Details: The Participant/nominated representative can be contacted on:Contact Name* Phone (H) Phone (W) Mobile* Email Address Street Address Address Line 2 Suburb State Postcode Alternative Contact Person The provider can be contacted on: Contact Name: Danielle Mathie Phone: 0434 619 017 Email admin@interactiveplanmanagement.com.au Address: PO Box 2082 Elizabeth Park SA 5113 Service Agreement Signatures:Signature of Participant/nominated representative*Name of Participant/nominated representative* Signature of authorised staff member from Interactive Plan Management Name of authorised staff member from Interactive Plan Management Pty Ltd Danielle Mathie NDIS plan Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 32 MB. Please upload a copy of your current NDIS plan.EmailThis field is for validation purposes and should be left unchanged.
