Individual Service AgreementThis Individual Service Agreement, hereinafter called the Agreement, is made between: _______________________________________________________________________ ............................................................. (Participant/Participant’s Representative Name)and the Crown in Right of Tasmania represented by the Department of Health and Human Services (DHHS) - Disability and Community Services (DCS): _______________________________________________________________________ ............................................................. (Service Provider Representative - Name and Discipline/Title)The start date for this agreement is: _ _/_ _/_ _ _ _ The end date for this agreement is: _ _/_ _/_ _ _ _This Agreement is made for the purpose of providing supports under the Participant’s National Disability Insurance Scheme (NDIS) Plan. The Parties agree that this Agreement is made in the context of the NDIS which is a scheme that aims to: support the independence and social and economic participation of people with

disability enable people with disability to exercise choice and control in the pursuit of their

goals and the planning and delivery of their supports.

1. Schedule of SupportsAs a provider of service or supports, Disability and Commuinity Services (DCS) agrees to provide:Item Description

Item Number

Rate Number of Hours

Total Cost

Goal

*These hours may be used for travel, assessment, consultation with other support providers, report writing and discussion of assessment outcomes within the Item. Travel determined as additional by NDIA may be listed on the Partipant Plan as as a separate item.

2. Support will be provided by:

Name:

Phone: Mobile:

Email:

Address:

3. Service Provider’s ResponsibilitiesDCS agrees to use its best endeavours to: provide the services agreed between the Participant and DCS at the

Participant’s prefered times treat the Participant politely and with respect be open and honest about the work we do explain things clearly give the Participant at least 24 hours notice if we need to change an

appointment include the Participant in all decisions about the supports/service let the Participant know what to do if they have a problem or want to

complain listen to the Participant’s feedback and fix any problems quickly tell the Participant if we want to end the agreement make sure the Participant’s information is right and up to date

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store the Participant’s information carefully and make sure it is kept private

follow all the rules and laws that apply including the Department’s Quality and Safety Framework, the Disability Services Act 2011, the National Disability Insurance Scheme Act 2013, and NDIS Rules and the Australian Consumer Law

have self insurance arrangements in place with the Tasmanian Risk Management Fund.

follow the Tasmanian State Service Code of Conduct check the Agreement is working well and review as needed or every 12

months as a minimum send regular invoices and statements of the supports provided.

4. Participant’s ResponsibilitiesI, ..........................................................(name of Participant or their representative) agree to: tell the Service Provider about the supports I want and how I want to

receive them be polite and respectful to the staff who work with me tell the Service Provider if I’ve got any problems give the Service Provider at least 24 hours notice if I cannot make an

appointment pay support hours for the Service Provider’s time if I haven’t given 24

hours notice of cancellation give the Service Provider at least two weeks notice if I want to change my

provider (refer to Point 7) tell the Service Provider straight away if I want to end the Agreement let the Service Provider know if my NDIS Plan changes or if I stop

accessing the NDIS.5. In-kind Support Payment Arrangements

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The NDIA will manage the in-kind funding for supports provided under this Service Agreement. After providing those supports, the Service Provider will claim in-kind payment for those supports from the NDIA.6. How to make changes to this Service AgreementThe Parties agree that any changes to the supports or their delivery must be in the Participant’s NDIS Plan. Any changes to this Agreement will be in writing, signed, and dated by both Parties.7. How to end this AgreementIf the Participant or DCS choose to end the Agreement, two weeks notice must be given.The Agreement can end without a notice period if the Participant or DCS break the Agreement in a serious way.8. Feedback, Complaints and DisputesIf the Participant is not happy with the provision of supports and wishes to make a complaint, or wishes to give the Service Provider feedback, the Participant can talk to the Service Provider Contact as detailed at Section 2 of this Agreement. If the Participant is not satisfied or does not want to talk to this person, the Participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting ndis.gov.au for further information.9. Contact DetailsThe [Participant / the Participant’s representative] can be contacted on:

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Name

Phone Mobile

Email

Address

Agreement SignaturesThe Parties agree to the terms and conditions of the Agreement.

Signature of Participant/Participant’sRepresentative

Name of Participant/Participant’sRepresentative

Date: __/__/____

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Signature of Authorised Person from DCS Name of Authorised Person from DCS

Date: __/__/____ [Attach a copy of the NDIA Request for Service.]

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