SERVICE AGREEMENT- NDIS

Provider: Joya Medical Australia Pty Ltd

Please note: All fields must be completed or the Service Agreement may not be able to be processed.

Please attach a copy of the Participant’s NDIS plan if possible, to assist in ensuring approved consumables are supplied.

Please email completed, signed copy to ndis@joyamedicalsupplies.com.au

    Participant Name:

    NDIS Number:

    Date Of Birth:

    Email Address:

    Contact Person:

    Contact Number:

    Provider:

    Joya Medical Australia Pty Ltd
    If Planner Managed, only a Biller Authorisation Form needs to be completed.

    Delivery Address:

    Support Coordinator Name:(If Applicable)

    Support Coordinator Contact Number:(If Applicable)

    Support Coordinator Email:(If Applicable)

    Plan Start Date (DD/MM/YY):

    Plan End Date (DD/MM/YY):

    Consumables Service Booking Amount:(i.e. How much do you want Joya Medical Australia to reserve monthly for your goods)

    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

    RESPONSIBILITIES OF PROVIDER

    The Provider agrees to:

    • Provide supports that meet the Participant's needs at the Participant's preferred times.

    • Communicate openly and honestly in a timely manner.

    • Treat the Participant with courtesy and respect.

    • Listen to the Participant's feedback and resolve problems quickly.

    • Give the Participant the required notice if the Provider needs to end the Service Agreement.

    • Protect the Participant's privacy and confidential information

    RESPONSIBILITIES OF PARTICIPANT / PARTICIPANT'S REPRESENTATIVE

    • Inform the Provider about how they wish the supports to be delivered to meet the Participant’s needs.

    • Give the Provider the required notice if the Participant needs to end the Service Agreement.

    • Let the Provider know immediately if the Participant’s NDIS plan is suspended or replaced by a new NDIS plan or the Participant stops being a participant in the NDIS.

    • To provide adequate information to the provider so a service booking can be made and funds claimed whilst remaining under budget.

    • If Joya Medical Australia Pty Ltd Australia is unable to claim the order amount from NDIS the participant will be liable for the balance of the unclaimed invoices.

    PAYMENTS

    The Participant has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, Joya Medical Australia Pty Ltd will claim payment for those supports from the NDIA.

    AGREEMENT SIGNATURES

    The Parties agree to the terms and conditions of this Service Agreement.

    Participant / Participant's Representative Name

    Provider Representative Name:

    Date:

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

    [signature* signature-173 color:#000000 backcolor:#dddddd width:300 height:200]

    Verbal consent given over phone as unable to complete and sign form online due to health condition

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