Yellow Door Therapy Services

Service Agreement

Date *

Service Agreement Type *

NDISPrivate

The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the Client’s NDIS 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, and
enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.

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 Yellow Door Therapy Services 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

Support Coordinator Name

Support Coordinator Email

Referrer Name

Referrer Email

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

WARNING!!!

Service Agreements are not applicable when the carer is Department Of Justice.

A Service Deed must be completed instead. Refer to SOP for process.

Other relationshipPlease specify

Rights and Responsibilities

Responsibilities of Yellow Door Therapy Services

Provide supports that meet the Client/Client’s Representative needs.
Communicate openly and honestly in a timely manner.
Treat the Client/Client’s Representative with courtesy and respect.
Consult the Client/Client’s Representative on decisions about how supports are provided.
Listen to the Client/Client’s Representative feedback and resolve problems quickly.
Protect the Client/Client’s Representative privacy and confidential information.

Responsibilities of the Client/Client's Representative

Inform the provider about how they wish the supports to be delivered to meet the Client’s needs.
Treat the provider with courtesy and respect.
Talk to the provider if the Client has any concerns about the supports being provided.
Give the provider a minimum of 24 hours’ notice if the Client cannot make a scheduled appointment. If the notice is not provided by then the provider will bill for service.

Responsibilities of the Client/Client's Representative

Inform the provider about how they wish the supports to be delivered to meet the Client’s needs.
Treat the provider with courtesy and respect.
Talk to the provider if the Client has any concerns about the supports being provided.
Give the provider a minimum of 24 hours’ notice if the Client cannot make a scheduled appointment. If the notice is not provided by then the provider will bill for service in line with current NDIS price schedule.
Let the provider know immediately if the Client’s NDIS Plan is suspended or replaced by a new NDIS Plan or the Client stops being a Client in the NDIS.

Responsibilities of the Client/Client's Representative

Inform the provider about how they wish the supports to be delivered to meet the Client’s needs.
Treat the provider with courtesy and respect.
Talk to the provider if the Client has any concerns about the supports being provided.
Give the provider a minimum of 24 hours’ notice if the Client cannot make a scheduled appointment. If the notice is not provided by then the provider will bill for service in line with current NDIS price schedule.
Let the provider know immediately if the Client’s NDIS Plan is suspended or replaced by a new NDIS Plan or the Client stops being a Client in the NDIS.
Pay invoices by the due date.

Responsibilities of the Client/Client's Representative

Inform the provider about how they wish the supports to be delivered to meet the Client’s needs.
Treat the provider with courtesy and respect.
Talk to the provider if the Client has any concerns about the supports being provided.
Give the provider a minimum of 24 hours’ notice if the Client cannot make a scheduled appointment. If the notice is not provided by then the provider will bill for service in line with current NDIS price schedule.
Let the provider know immediately if the Client’s NDIS Plan is suspended or replaced by a new NDIS Plan or the Client stops being a Client in the NDIS.
Advise Yellow Door Therapy Services if your Plan Manager details change.

Cancellation Policy

Short notice cancellations or non-attendance, where notice is given with less than 24 hours notice 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, Yellow Door Therapy Services 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.

Repeated cancellations may result in cessation of this agreement.

Should Yellow Door Therapy Services be unavailable due to illness or unexpected personal leave, therapy for that day may be cancelled and the Therapist will attempt to notify you as early as possible; and no charge will be incurred by the Client for that day’s therapy.

Clients and/or their Representative need to contact your nominated Therapist to cancel an appointment.

Short notice cancellations or non-attendance, where notice is given with less than 24 hours notice 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.

Repeated cancellations may result in cessation of this agreement.

Should Yellow Door Therapy Services be unavailable due to illness or unexpected personal leave, therapy for that day may be cancelled and the Therapist will attempt to notify you as early as possible; and no charge will be incurred by the Client for that day’s therapy.

Clients and/or their Representative need to contact your nominated Therapist to cancel an appointment.

Schedule of Supports

Service Start Date *These are the dates in which Yellow Door Therapy Services will be providing support.

Service End Date *

Is this an Update on a Current Service Agreement for this Plan Period *

Updated Hours for this Service Agreement Plan Period

Note:This Service Agreement reflects an extension of Occupational Therapy services. Additional hours have been added to the previously approved allocation under the current NDIS plan period.

Previously Approved OT Hours

Previous Approved Budget

Below are the ADDITIONAL HOURS of Occupational Therapy Support for approval:

Additional Hours Requested

Additional Budget Requested

Total Hours (incl previously approved)

Total Budget (incl previously approved)Inclusive of Therapy funding already used

The TOTAL hours are for this plan period, including hours already used.

This calculation reflects the additional hours of support added to the original hours approved, with the new total hours for this plan period.

Hours Requested for this Service Agreement Plan Period

Occupational Therapy Hours *Inclusive of Therapy funding already used

Total Budget

Private Occupational Therapy Hours

Hourly Rate *

Private Travel *

Travel Rate *

Total Budget

Funding Category *

NDIS OT Assistance with Daily Life Item Code: 01_661_0128_1_3

NDIS OT Improved Daily Living Item Code: 15_617_0128_1_3

Please provide information regarding Approval of using CORE funds *

Occupational Therapist

Email Address

Based on the information about you that we have received,
we have determined that the Supports are reasonable and necessary for your specific needs.

Type of Support:

Clinical assessment and therapy interventions
Clinically relevant communications including phone calls/written programs/communication with other service providers and progress notes
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
Travel to provide service

Costs :

Yellow Door Therapy Services charges the NDIS rates. The current rate is $193.99 per hour for all supports listed in Types of Supports section of this Service Agreement.

The price rate is subject to change annually on 1st July. Rates will be adjusted to remain in line with changes made by NDIS after the end of this current service period.

An additional km travel charge may be charged in line with the current NDIA price guide and this will be discussed with you prior.

Additional expenses (i.e. things that are not included as part of a Client’s NDIS supports) are the responsibility of the Client / Client representative and are not included in the cost of the supports. Examples include entrance fees, event tickets, meals, etc.

Type of Support:

Clinical assessment and therapy interventions
Clinically relevant communications including phone calls/written programs/communication with other service providers and progress notes
Attendance at team meetings/case conferences
Assessment and trial of equipment as required
Any reports, forms, or letters as required or requested by the Client / Client representative
Cancellation charges for late notice or no show appointments
Travel to provide service

Rate per hour for Private OT Services

Costs :

The current rate is listed above for all supports listed in Types of Supports section of this Service Agreement.

The price rate is subject to change annually on 1st July. An additional km travel charge may be charged and this will be discussed with you prior.

Additional expenses are the responsibility of the Client / Client representative and are not included in the cost of the supports. Examples include entrance fees, event tickets, meals, etc.

Payments

Yellow Door Therapy Services will seek payment for their provision of supports after the supports have been delivered:

Billing email address for Private Clients *

Yellow Door Therapy Services will seek payment for their provision of supports after the supports have been delivered in accordance with the Client's NDIS Plan funding type noted below:

Type *

AGENCY MANAGED - The Client is managed directly by the NDIA. After providing supports, Yellow Door Therapy Services will claim these directly from a Service Booking on the PRODA Portal.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, Yellow Door Therapy Services will send the Client / Client representative an invoice for those supports for the Client / Client representative to pay from: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, Yellow Door Therapy Services will claim payment for those supports from:

The Client/Client's Representative will need to call the NDIS on 1800 800 110
and endorse Yellow Door Therapy Services as a MyProvider on the Plan.

NDIS Provider Number: 40 500 357 42
ABN: 36 620 134 296

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

Email for billing:

Plan Manager *

Plan Manager Email *

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

If invoice payments for the Client’s services are overdue, services will be placed on hold until payment is made.

Yellow Door Therapy Services reserves the right NOT to provide service and to cancel any future appointments for the Client if you do not have sufficient funds in your Plan, the Plan expires or the invoices are not paid within 14 days. Any service fees not met by NDIS will be covered by the Client / Client representative.

If payments continue to remain outstanding for more than 2 months or are repeatedly outstanding, then services will be cancelled permanently.

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

If invoice payments for the Client’s services are overdue, services will be placed on hold until payment is made.

Yellow Door Therapy Services reserves the right NOT to provide service and to cancel any future appointments for the Client if the invoices are not paid within 14 days.

If payments continue to remain outstanding for more than 2 months or are repeatedly outstanding, then services will be cancelled permanently.

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, by the parties.

Should either party wish to end this Service Agreement, they must give 2 week’s notice.

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

Feedback, Complaints and Disputes

If the Client wishes to give the provider feedback, they can contact the provider in person, via phone, email, website, or post. Director details for Yellow Door Therapy Services are listed at the end of this Agreement:

If the Client is not satisfied or does not want to discuss with the provider, the Client can contact
- the NDIS Quality and Safeguards Commission on 1800 035 544.

Confidentiality and Consent

The Client consents to the provider to consult with and provide Occupational Therapy reports to relevant parties including but not limited to NDIA, your other therapy services and Support Coordinator and Service Coordinator, where relevant to achieving the Clients goals.

The Client consents to the provider to consult with and provide Occupational Therapy reports to relevant parties including but not limited to your other therapy services and referral company, where relevant to achieving the Client's goals.

I understand and agree to the terms and conditions of this Service Agreement.I consent to my provider taking photographs for the purpose of providing their supports and inserting in reports if required.I consent to participate in a service satisfaction survey.I consent to participating in a NDIS quality management activity which may include being contacted by a third party auditor.I consent to my provider sharing and obtaining pertinent information with my other service providers and representative with the exclusion of

I understand and agree to the terms and conditions of this Service Agreement.I consent to my provider taking photographs for the purpose of providing their supports and inserting in reports if required.I consent to participate in a service satisfaction survey.I consent to my provider sharing and obtaining pertinent information with my other service providers and representative with the exclusion of

Review Agreement

If you wish to agree and sign this Service Agreement please choose YES below

If you need any changes made to this Service Agreement please choose NO below

Are all details correct? *

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

Please explain what you need changed in this document

Review Note *

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

Please hit "Submit" button below to proceed.

Agreement Signatures

I consent for my Signed Service Agreement to be provided to:

my Plan Manager (if appropriate)my Support Coordinator

Plan Manager Email

Support Coordinator Name *

Support Coordinator Email *

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 Yellow Door Therapy Services 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 of Client/Client's Representative *