Evolve NDIS Service Agreement

A Service Agreement can be made between a Client or their Authorised Representative (e.g. a parent, guardian or other nominated person) and a Provider.

In this Service Agreement, the term "Party" or "Parties" refers to Evolve Therapy Collective (Evolve TC) and the Client/Client's Authorised Representative who is making this Agreement.

Client Details

Client First Name *

Client Surname *

The Person that is Authorised to sign this Service Agreement is:

The Client? *

The Authorised Representative? *

Client's Authorised Representative *

and Practice Name

Referrer/Support Coordinator Name

Referrer/Support Coordinator Email

The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Client's National Disability Insurance Scheme Plan.

The Parties agree that this Service 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 a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports, and

- The supports in this Service Agreement are reasonable and necessary for the Client.

Contact Details

Client First Name

Client Last Name

Client Date Of Birth *

NDIS Number *

Phone *

Email

Address *

Client Representative Name

Client Representative Phone *

Client Representative Email *

Client Representative Address

Relationship to Client

Consent

At times, it may be helpful for us to talk with other people involved in your care. Only information relevant to the service we are providing will be discussed. We will not talk with anyone that you do not want us to speak with.

The Client/Client Representative consents to Evolve TC specifically liaising with:

Schedule of Supports

Any particular stipulations to be included in this Service Agreement

Hardcopy of SA required? Admin use only

Update on Current Service Agreement for this Plan Period

Previous Service used *

Previously used hours

Previous used Psych hours

Service Start Date *These are the dates in which Evolve Therapy Collective will be providing supports

Service End Date *

Supports to be provided *

Occupational TherapyPsychologyPhysiotherapySocial Work

Services may also be delivered by a Therapy Assistant Level 2 under instruction from the treating Therapist.

Funding Category *

Other line item information *Category, Subcategory, Item Code, Description, Rate per hour

Please prepare my funding in

Occupational Therapy Dollars *

Occupational Therapy Hours *

Physiotherapy Dollars *

Physiotherapy Hours *

Social Work Dollars *

Social Work Hours *

Psychology Dollars *

Psychology Hours *

Therapy Assistant Level 2 Dollars *

Therapy Assistant Level 2 Hours *

Total previously used dollars Previously used Therapy dollars

Total previously used dollars Previously used Psychology dollars

Total BudgetInclusive of Psychology funding already used

Total HoursInclusive of Psychology hours already used

Total BudgetInclusive of Therapy funding already used

Total HoursInclusive of Therapy hours already used

Total Budget in Dollars

Total Funding in hours

Occupational Therapist *

Email *

Social Worker *

Email *

Psychologist *

Email *

Physiotherapist *

Email *

Therapy Assistant

Email

Type of Support:

Clinical assessment and treatment
Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 6 minutes will be invoiced)
Attendance at team meetings/case conferences
Assessment and trial of equipment as required
Any reports, forms, or letters as required by the NDIS or requested by the client / client representative
Cancellation charges for late notice or no show appointments

Evolve TC reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds in your plan or the plan expires. Any service fees not met by NDIS will be covered by your client / client representative.

Price and Payment Information:

The hourly rate is in accordance with the conditions stated in the NDIS Pricing Arrangement. The hourly rate, travel rates and guidelines for services included (including cancellation policy) will be subject to change, in accordance to changes to the NDIS Pricing Arrangement. The fees are:

Occupational Therapy: $193.99 per hour plus $193.99 per hour for any associated therapist travel.
15_617_0128_1_3
Psychology: $222.99 per hour plus $222.99 per hour for any associated therapist travel.
15_054_0128_1_3
Physiotherapy: $193.99 per hour plus $193.99 per hour for any associated therapist travel.
15_055_0128_1_3
Social Work: $193.99 per hour plus $193.99 per hour for any associated therapist travel.
15_621_0128_1_3
Therapy Assistant Level 2: $86.79 per hour plus $86.79 per hour for any associated therapist travel.
15_055_0128_1_3

If any Evolve TC Therapist arrives to a confirmed appointment, and the Participant declines service, is not present or does not show up after contact attempts, then both non-attendance of the appointment and any relevant travel will be charged.

Travel
Travel will be charged in accordance with NDIS guidelines for Capacity Building Supports. Guidelines currently specify travel to and from appointments is billable at an hourly price limit in the following increments:

- Up to 30 minutes for MMM1-3 areas and
- Up to 60 minutes for MMM4-5 remote areas

IMPORTANT NOTICE: Please review the changes specified here regarding the line item used for this specific Service Agreement, as they differ from those listed above.

Payments

Please note this an updated Service Agreement to include

both previously used hours and further requested hours for this Plan period.

Evolve TC will seek payment for their provision of supports after the supports have been delivered in accordance with the clients plan funding type noted below:

SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Evolve TC will send the client / client representative an invoice for those supports for the client / client representative to pay. NDIA MANAGED - The client has nominated the NDIA to manage the funding for supports provided under this Agreement. After providing those supports, Evolve TC will claim payment for those supports from the NDIA. PLAN MANAGED - The client has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Evolve TC will claim payment for those supports from:

Email for billing *

Plan Manager *

Plan Manager Email *

Payment is due by Electronic Funds Transfer within 14 days of invoicing.

Agency management: *

We will create a Service Booking on PRODA Portal and claim invoices directly

The Client/Client's Representative will need to call the NDIS on 1800 800 110
and endorse Evolve as a provider on their plan.

Our NDIS Registration Number is: 405 007 8738

This applies to each Plan period, even if there have been services with Evolve in the last Plan.

Click here for more information about PACE

Evolve Therapy Collective - a.b.n. 88 268 331 421

NDIS Registered Provider - 4050078738

Copy of Client's NDIS Plan

It is helpful for the Therapist to have a copy of the My Profile and Goals sections of the NDIS Plan. This ensures we are working towards your stated goals. It also helps when applying for funding and completing reports for the NDIS when needed. It is helpful to include the Funding Sections of your Plan, especially if you need to apply for Assistive Technology; Home Modifications or Home and Living Supports.

It is your choice whether or not to provide a copy of all or parts of the NDIS Plan.

NDIS Plan for the current period

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Rights & Responsibilities

Evolve TC agrees to;

Provide Therapy services as per this agreement and in accordance with NDIA procedures.
Work in collaboration with you to achieve your goals.
Communicate openly and honestly with you.
Be polite and friendly and treat you with respect at all times.
Explain things clearly so you understand every step of the process.
Include you in all decisions about your supports.
Listen to your feedback and act quickly upon any complaints you report to us.
Store your information carefully and maintain your privacy

You agree to;

Notify Evolve TC about any changes you wish to be made to this Service Agreement.
Notify Evolve TC if your NDIS plan changes (e.g. if you have a booked plan review).
Provide at least 48 hours notice if you wish to cancel a booked service.
Provide at least 48 hours notices if you wish to terminate our services. You will be billed for the hours of service provided to the date of termination.
Pay invoices by the due date.

Cancellation Policy

Short notice cancellations or non-attendance, where notice is given with less than 2 clear business days before the scheduled appointment, may result in 100% of the appointment fee being charged (except in extenuating circumstances), including any travel (or part thereof) already undertaken.

The NDIS allows for the Client's Plan to be charged for late cancellations/failure to attend by Clients. If there are frequent cancellations, Evolve TC will contact you to try to understand why they are occuring and see if anything needs to change in the delivery of the therapy services to support the Client. Clients must pay for any cancellation fees not covered by the NDIS.

Outstanding Fees

Outstanding fees need to be paid prior to further services being provided. If fees are not paid, Evolve TC may contact the following (where applicable) to recover the outstanding debt:

Plan Manager
Support Coordinator
LAC/ECEI Partner
NDIA
Debt collector
The Client/Client's Representative will be liable for any outstanding debts that are not payable by the NDIA and also the costs associated in recovering such debts.

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 Client's NDIS plan currently in effect under section 37 of the NDIS Act;

- the Client's NDIS plan is expected to remain in effect during the period the supports are provided; and

- the Client/Client's Authorised Representative will immediately notify Evolve TC if the Client's NDIS plan is replaced by a new plan, or if the Client stops being a client within the NDIS.

Making a Complaint

We will strive to ensure that your experience with Evolve TC is a positive one, however in any instance where you are unhappy with our service, feel free to discuss this with us as soon as possible. Please be assured that we welcome all feedback and will endeavour to resolve any issues or concerns in a timely manner.

If you have a concern, please complete our feedback form via this link. This is able to be completed anonymously.

Alternatively, you can speak directly to either of the Evolve TC directors:

Angie Brown Fiona Williams
T: 0437 214 077 T: 0431 574 040
E: angie@evolvetc.com.au E: fiona@evolvetc.com.au

If you don’t wish to discuss your complaint with Evolve TC, or if you feel that your issue is not being resolved satisfactorily, you can contact your NDIS Support Coordinator or Plan Manager. Alternatively, you can contact the NDIA who can provide you with information on what you can do.

NDIA T: 1800 800 110 http://www.ndis.gov.au

Changes to this Service Agreement

If changes to the supports or their delivery are required, 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 the Parties.

Ending this Service Agreement

Should either Party wish to end this Service Agreement they must give 48 hours notice.

If either Party seriously breaches this Service Agreement the requirement of notice will be waived.

Signatures

Are all details correct? *

Yes - proceed to signing Service AgreementNo - please review and update

Please specify what details you need to have changed in this Service Agreement prior to your signature

We will then send back an updated amended copy of this Service Agreement back to you for consent and signature.

By signing this Agreement, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Agreement and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this Agreement.

I have read & understood this Service Agreement and understand each item listed within. I understand Evolve TC will be engaged to provide services that it is entitled to receive payment in return.

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Agreement as the Client's Authorised Representative.

Signature *

Draw signature|Type signatureClear

Client

Date

Name of Authorised Representative Signing this Agreement on behalf of:

Date

Client

Date

ADMIN USE ONLY: PDF consent information

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If required: please attach proof of consent that came through on email

Thank you - we will review your response promptly and return an updated form for you to approve.

Please hit "Submit" button below to proceed.

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