Referral Type

Service Type

PhysiotherapistOccupational TherapistSpeech PathologistDietitian

You may select multiple options

Preferred Service Location

PART 1: SCHEDULE OF SUPPORTS

All NDIS services must only be commenced after a quote is approved by the participant's representative. Please select the services you would like below and the system will auto generate a quote for you. We cannot provide NDIS services without an appropriate quote being approved.

NDIS Quote

Physio Clinical Service *

Physio Initial Assessment and ReportPhysio Follow Ups

Please select both options if you would like an initial assessment and follow ups

OT Clinical Service *

Functional Capacity Assessment and Report - Adults Functional Capacity Assessment and Report - Paediatrics 0 -13 yo Functional Capacity Assessment and Report - Paediatrics 14 -18 yo SIL Assessment and Report SDA Assessment and Report Assistive Technology (AT) Assessment and Report OT Follow Ups

Please select both options if you would like an initial assessment and follow ups

SP Clinical Service *

SP Initial Assessment and ReportSP Follow Ups

Please select both options if you would like an initial assessment and follow ups

Dietetics Clinical Service *

DT Initial Assessment and ReportDT Follow Ups

Please select both options if you would like an initial assessment and follow ups

Number of physiotherapy follow up sessions *Please state how many physiotherapy follow up sessions you require within the booking dates stated above

Number of OT follow up sessions *Please state how many OT follow up sessions you require within the booking dates stated above

Number of Speech Pathology follow up sessions *Please state how many speech pathology follow up sessions you require within the booking dates stated above

Number of dietetics follow up sessions *Please state how many dietetics follow up sessions you require within the booking dates stated above

Physiotherapy Quote

Occupational Therapy Quote

Speech Pathology Quote

Dietetics Quote

Final NDIS Quote

Please ensure you allocate adequate funds for travel charges. Exceptions can be made to travel charges where multiple participants live in the same household and/or where Ritco Allied Health has agreed to waive travel charges for exceptional circumstances

NDIS Quote Approval

Do you have the authority to approve the above NDIS quote? *

YesNo

If no, please state details of how this quote is being provided to the NDIS participant/representative? *

Full Name *Please type in your full name

Designation/Relationship to NDIS Participant *For e.g. Support Co-ordinator or parent etc.

Signature of person approving the quote *

Draw signature|Type signatureClear

Service User Agreement Authorisation

Do you have the authority to sign a Service User Agreement on behalf of the participant? *

YesNo

Who will be signing the NDIS Service User Agreement? *

NDIS ParticipantParticipant Family/Representative/EPOAOffice of the Public Guardian (OPG)

Family/Representative Full Name *

Family/Representative Email *

Family/Representative Phone *

PART 2: NDIS SERVICE USER AGREEMENT

All NDIS referrals must have a signed service user agreement in place prior to service commencement. Please fill out the below service agreement if you are authorised to do so. We cannot provide services to any participant without the service agreement being signed

1. Parties

This Service Agreement is for a participant in the National Disability Insurance Scheme, and is made between: *

and the Provider:

Ritco Pty Ltd trading as Ritco Physiotherapy & Allied Health

This Service Agreement will commence on date stated below for an ongoing period until service is deemed as reasonable and necessary for the Participant *

2. The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the participant’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.

3. Schedule of Supports

The provider agrees to provide the participant with mobile allied health services as per below for an ongoing period, until the service is deemed as reasonable and necessary for the participant: *

PhysiotherapyOccupational TherapySpeech PathologyDietetics

Support will be provided at the current NDIS rate as stipulated in the NDIS pricing guide for the current financial year, per hour inclusive of all taxes. This rate will increase in accordance with the NDIS pricing guide each time the NDIS increases their rates.

It is understood that by signing this agreement, you agree to any rate increase stipulated in the NDIS pricing guide as updated each yaer.

An additional travel charge will be applied per session on top of the support provision rate. The travel charge and the current therapy NDIS rate has been stipulated in the Schedule of Supports Quote provided to the participant/participant respresentative in this form. By signing this agreement, the participant/participant representative agree to the charges as quoted in the Schedule of supports section.

Additional expenses (i.e. things that are not included as part of a Participant's NDIS supports) are the responsibility of the participant/participants representative and are not included in the cost of the supports. Example include entrance fees, event tickets, meals, etc. if applicable.

4. Responsibilities of the Provider

The provider agrees to:

Review the provision of supports as requested by the participant/participant's representative
Once agreed, 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
Consult the participant on decisions about how supports are provided
Give the participant information about managing any complaints or disagreements and details of the provider’s cancellation policy (if relevant)
Listen to the participant’s feedback and resolve problems quickly
Give the participant a minimum of 24 hours’ notice if the provider has to change a scheduled appointmentto provide supports
Give the participant the required notice if the provider needs to end the Service Agreement (see Ending this Service Agreement below for more information)
Protect the participant’s privacy and confidential information
Provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law; keep accurate records onthe supports provided to the participant
Issue regular invoices and statements of the supports delivered to the participant.

5. Responsibilities of the participant/participant’s representative

The participant/participant’s representative agrees to:

Inform the provider about how they wish the supports to be delivered to meet the participant’s needs
Treat the provider with courtesy and respect
Talk to the provider if the participant has any concerns about the supports being provided
Give the provider a 7 days notice if the participant cannot make a scheduled appointment; and if the notice is not provided by then, the provider’s cancellation policy will apply.
Give the provider the required notice if the participant needs to end the Service Agreement (see Ending this Service Agreement below for more information), and
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

6. Payments

Ritco Physiotherapy & Allied Health will seek payment for their provision of supports after the supports have been delivered *

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, Ritco Physiotherapy & Allied Health will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by direct debit / EFT within 7 days.

NDIA MANAGED - The client has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, [Practice Name] will claim payment for those supports from the NDIA.

PLAN MANAGED - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Ritco Physiotherapy & Allied Health will claim payment for those supports from the plan manager.

7. Cancellation Policy

The provider reserves the right to claim payment for cancellation of treatment sessions where the cancellation notice period 7 days or less, before the day of appointment.

These sessions will be charged at 100% of the support session rate as stipulated by the NDIS price guide. No travel charges can be claimed by the provider for cancelled sessions unless the practitioner has arrived at an appointment and the client/participant is a not present at the place of support. In these cases, travel charges will also apply.

For sessions declined by participant when provider is in attendance at residence with no prior notice of non-consent to treatment given by participant, the provider reserves the right to claim 100% payment for session and travel charges.

8. 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.

9. Ending this Service Agreement

Should either party wish to end this service agreement, they must give 4 weeks notice of termination in writing. If either party seriously breaches this Service Agreement the requirement of notice will be waived.

10. Health and Safety

Ritco Physiotherapy & Allied Health is committed to the health and safety of its clients and staff

Please note, we have a zero tolerance policy for abuse and reserve the right to have our practitioners and/or clients immediately cease and/or exit any appointment they deem unsafe for their health and safety

During the period of investigation into a reported incident of abuse, we reserve the right to temporarily suspend services until the incident investigation of the reported incident is concluded

In the event that a reported incident of abuse is investigated and deemed unsafe for staff and/or clients, we reserve the right to end this Service User Agreement with immediate effect and/or with 24 hours notice of closing an incident investigation, in the interest of the health and safety of our client and/or staff

Australian Health Law states that clients under the age of 18 are considered to be paediatric and must have a responsible supervising adult (over the age of 18) present during the appointment (including telehealth appointments)

We reserve the right to have our practitioners cease and/or exit an appointment with a paediatric client, at any time, wherein a responsible supervising adult (over the age of 18) is unable to be present

As per the guidelines on Child Safety from the National Health and Medical Research Council (NHMRC), we reserve the right to call Emergency Services (000) if we deem a child to be in immediate danger

11. Feedback, complaints and disputes

If the participant wishes to give the provider feedback, the participant can talk to Ritco Physiotherapy & AlliedHealth on 1800 474 826 (1800 4 RITCO) or email: enquiries@ritcophysiotherapy.com.au

If the participant is not happy with the provision of supports and wishes to make a complaint, the participant can talk to Ritco Physiotherapy & Allied Health on 1800 474 826 (1800 4RITCO) or email:enquiries@ritcophysiotherapy.com.au

If the participant is not satisfied, the participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting www.ndis.gov.au for further information.

12. 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 participant’s NDIS plan currently in effectunder section 37 of the NDIS Act;
The participant’s NDIS plan is expected to remain in effect during the period the supports are provided;and
The participant/participant’s representative will immediately notify the provider if the participant’s NDIS Plan is replaced by a new plan or the participant stops being a participant in the NDIS.

13. Contact Details

The participant/the participant’s representative can be contacted on:

Participant/Representative Name *

Phone Number *

Email Address *

The provider, Ritco Physiotherapy & Allied Health, can be contacted on:

Phone: 1800 474 826

Email: enquiries@ritcophysiotherapy.com.au

14. Agreement Signatures

The parties understand and agree to the terms and conditions of this Service Agreement:

Signature of Provider Representative:

_______________________________________________

Name of Provider Representative

Signature of Participant Representative: *

Draw signature|Type signatureClear

Name of Participant/Representative *

Signed Date: *

Client Details

Client First Name *

Client Last Name *

Date of Birth *

NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Mobile *Please provide the mobile number to receive appointment notifications.

Client Email Address *Please provide the email address to receive appointment notifications

Address *

Postcode *

Primary Diagnosis *

DVA Number *

Funding Type *

Treatment invoices to be sent to? *Please state email address for fund manager

Reason for Referral *Please state why you require this service, for e.g your main reason for referral, the client's primary impairment

GP DVA Referral *

Browse

Please attach a copy of the DVA Referral from the GP. We cannot service any DVA referrals without a copy of this plan

Medicare/EPC/CDM Plan *

Browse

Please attach a copy of the EPC/CDM plan from the GP. We cannot service the referral without a copy of this plan

Please attach any files/documents that may be important for our information

Browse

This could be a copy of the NDIS plan, medical history or any other attachment as necessary and applicable

Invoice Information

Who will be paying for the invoice? *

Residential Aged Care FacilityResident/FamilyPublic GuardianOther

Name of Aged Care Facility *

Resident/Family Member Name *

Facility Contact Name

Facility Contact Number *

Resident/Family Contact Number *

Please state the email address to send invoice to *

Enduring Power Of Attorney (EPOA) Details

EPOA Full Name *

Phone *

Email *

Referee Details

Referee Full Name *

Referee Phone *

Email *

Organisation *Please state the organisation you represent, for example ABC support co-ordination partners

Designation *For example support co-ordinator, clinical manager etc.

Health and Safety Disclaimer

We take the health and safety of our staff members seriously. As such, we have the right to refuse to service or decline a referral which lists behaviours of concern/other safety issues which may cause potential harm to our staff.

Please ensure that you complete this section honestly and provide as much information as possible to enable us to service your participant/client adequately

Are there any behaviours of concern or previous incidents with this participant/client that we should be aware of, that may cause potential harm by way of physical/verbal assault, inappropriate sexual and/or aggressive behaviours towards our staff? *

YesNo

If yes, please outline in detail any behaviours of concerns below. Please provide as much information as possible. *

Health and Safety Disclaimer: Child Safety

Are you referring a client/child who is under the age of 18? *

YesNo

Australian Health Law states that clients under the age of 18 are considered to be paediatric and must have a responsible supervising adult (over the age of 18) present during the appointment (including telehealth appointments)

We reserve the right to have our practitioners cease and/or exit an appointment with a paediatric client, at any time, wherein a responsible supervising adult (over the age of 18) is unable to be present

As per the guidelines on Child Safety from the National Health and Medical Research Council (NHMRC), we reserve the right to call Emergency Services (000) if we deem a child to be in immediate danger

Have you read and understood the above health and safety guidelines? *

YesNo

Disclaimer/Terms of Service

Do you agree to our privacy policy stated below? *

YesNo

Please click on the link to read our Privacy Policy: https://www.ritcophysiotherapy.com.au/privacy-policy /

Do you agree to our website terms and conditions stated below? *

YesNo

Please click on the link to read our website Terms and Conditions: https://www.ritcophysiotherapy.com.au/terms-conditions/

Covid-19 Declaration

Are you aware of the client or any members of their household having Covid-19/Flu-like symptoms? *

YesNo

Symptoms include fever, sore throat, cough, headaches, difficulty breathing, chest pains, body aches and pains