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(08) 6373 6800 General enquiries : LD@distilmanagement.com.au | Plan management (Invoices) : admin@distilmanagement.com.au

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Plan Management Service Agreement

Form Role

Who is completing this form? *

I am an NDIS Participant

I am a Parent, Nominee, Guardian or Authorised Representative of an NDIS Participant

Service Agreement Consent *

This Service Agreement is for a Participant on the National Disability Insurance Scheme (Participant), and is made for NDIS Plan Management services and supports. You nominate Distil Management to manage funding for NDIS Supports as per the below agreement. This Service Agreement is made between Distil Management (the Provider) and You (the Participant):

Yes, I would like Plan Management services to be provided by Distil Management

First Name *

Last Name *

Postal Address

Email *

Phone *

Date of Birth *

Plan Start Date

Plan End Date

NDIS Number *

Preferred Contact Method (select an option) *

Phone Call

SMS/Text

Post

Easy English

How Did You Hear About Us?

Social Media

Google Search

Word of Mouth

Support Coordinator Referral

Other

Is there a Plan Nominee, or someone other than the Participant, who is responsible for the Plan and has legal authority to make decisions on behalf of the Participant?If YES, please provide details below. *

Yes

Allow your Plan Nominee/Authorised Representative access to:

Online Dashboard

Monthly Statements

Do you have a Support Coordinator? *

Yes

Allow your Support Coordinator access to:

Online Dashboard

Monthly Statements

Consent to Share: By ticking the box on the sign-up page, you agree to the terms and conditions as outlined in this Service Agreement. The Participant agrees to share their NDIS plan and information with Distil Management, as well as the Participant’s Support Coordinator, Local Area Coordinator (LAC) and NDIA Planner. If you do not understand any section of this agreement, please talk to a family member your nominee / representative / guardian or contact LD@distilmanagement.com.au to obtain further clarity before acknowledging consent. If you wish to provide Consent to Share information with other providers or contacts, please select below:

Authorised Representative

Allied Health Providers (ie OT/Physio etc)

Please attach a copy of your NDIS Plan

Invoice Approvals: When we receive invoices to pay from your NDIS plan, how do you wish to review them? Please choose one of the below methods for reviewing/approving your Support Providers’ invoices: *

I wish to have two days to review and approve each invoice before it is paid. If I do not check and approve/decline the invoice during this time, the invoice will be automatically paid once the two days has passed.

I wish to have all invoices paid automatically once they are received by Distil Management. I will keep Distil Management up to date with any changes in my expected supports and providers. I will check my monthly NDIS budget statement to ensure invoice payments are correct and I will contact Distil Management if I have any questions or concerns.

Agreement Acknowledgements *

I am the NDIS Participant named above, or I am the Plan Nominee or legal representative of the NDIS Participant named above and I am authorised to submit this Service Request. The details I have provided above are true and correct.

I agree to Distil Management's Terms & Conditions.

View Terms & Conditions

Your Signature

Today's Date *

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Supporting NDIS participants with Plan Management and Support Coordination.

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7/18 Parry Street,
Fremantle WA 6160
LD@distilmanagement.com.au
(08) 6373 6800

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Plan Management Service Agreement

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