BILLER AUTHORITY DEED

This Deed must be completed and submitted to Joya medical supplies by the Participants or Organisation responsible for paying the invoices. This Deed will enable the Client (or their representative) to place orders.

For NDIS, home care and other funded customers, please email the completed form to Click to send an email ndis@joyamedicalsupplies.com.au

Please ensure all details are completed and correct before submitting for processing

Please complete both pages of the Biller Authority Form before submitting

    Section 1:

    Recipient Full Name (Client):

    Recipient Address:

    Funding Type: (e.g. NDIS, HCP)

    NDIS Number:

    Date of Birth: (mandatory for NDIS)

    Recipient Contact Number:

    Recipient Email Address:

    Support Coordinator Name:(If Applicable)

    Support Coordinator Contact Number:(If Applicable)

    Support Coordinator Email:(If Applicable)

    Funding Start Date:

    Funding End Date:

    Expected monthly Spend During Funding Period (With Joya):

    Other Notes:

    Authority to leave:

    If you select No, signature on delivery will be require, If no one home the parcel will be taken to nearest collection centre

    Section 2:

    If invoice to be paid by client representative or organisation responsible to pay, please complete below section as well

    Biller Name: (Funding Manager):

    ABN:

    Biller Postal Address:

    Biller Email Address:(for invoice & statements)

    Biller Contact Name:

    Biller Contact Phone #:

    The Provider:

    • acknowledges that they will be liable for knowingly placing an order that exceeds the Recipient’s funding balance or was aware/could foresee that the client’s funding would be insufficient to meet the total cost of the order or the items ordered are not covered under the client’s plan

    • is solely responsible for advising Joya medical supplies in writing if the client’s fund is materially reduced or ceases.

    • has obtained the authority of their client to use and share the information to facilitate the fulfilment of orders.


    Our Privacy Policy can be found at https://joyamedicalsupplies.com.au/privacy-policy/

    Signed as an Agreement for the Provider

    Provider Representative Name:

    Participant / Participant's Representative Name:

    Date: (DD/MM/YYYY)

    Provider / Participant's Representative Signature OR Provider Representative Signature:

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