Consent Form

Participant Consent Form

This Form is part of a workflow.

Approvers Dylan Kable

Part A: Participant Details

Part A: Participant Details

Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker please put your details in the last few fields below

If Plan Managed, Please provide Email for Invoicing invoices@gmail.com

What category do you want What Ability to claim from?* Core Support

If Core Support what line item?

Social and Community Participation

If Capacity Building what line item?

Third Party consent is obtained so information on your support plan can be communicated government agencies. For example, you can agree to the third party making a request a plan review where you have a change in circumstances a review of a decision made by the What Ability

If you are completing this form on behalf of a participant, please indicate

NDIS PL AN START DATE dd/mm/yyyy

NDIS PL AN END DATE dd/mm/yyyy

NDIS PL AN MANAGEMENT TYPE

Plan Managed

Self Managed

NDIA Managed

IF PL AN MANAGED, PLEASE PROVIDE EMAIL FOR INVOICING

WHAT CATEGORY DO YOU WANT WHAT ABILITY TO CL AIM FROM?

IF CORE SUPPORT WHAT LINE ITEM?

IF CAPACITY BUILDING WHAT LINE ITEM?

I CONSENT FOR STAFF TO ASSIST ME ( THE PARTICIPANT ) WITH HANDLING MONEY (EG BUYING LUNCH) AND PERSONAL PROPERTY DURING BOOKINGS*

Yes No

I CONSENT TO MY PERSONAL INFORMATION IN RECORDED MATERIAL /FORMATS (E.G. IN AUDIO AND/OR VISUAL FORMATS) TO BE COLLECTED, USED AND RETAINED BY WHAT ABILITY* Yes No

If you are completing this form on behalf of a participant, please indicate

FIRST NAME

Participant Consent Form

Approved

This Form is part of a workflow. Workflow Assignee

Approvers Dylan Kable

Part A: Participant Details

Part B: Third Parties ( Person and/or organisation 1 and/or family group)

Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker please put your details in the last few fields below Participant Full Name

Third Party Consent

Third Party consent is obtained so information on your support plan can be communicated to family members, carers, other providers and relevant government agencies. For example, you can agree to the third party making a request on your behalf for: a plan review where you have a change in circumstances a review of a decision made by the What Ability Assistive Technology, Home Modi cations or other funded supports, or making arrangements or providing information for a plan being developed

You can choose to provide your consent for ALL areas, or use the boxes below to choose speci c areas you wish to provide consent for.

FULL NAME AND/OR NAME OF ORGANISATION 1

Method*  Plan Managed

If Plan Managed, Please provide Email for Invoicing invoices@gmail.com

What category do you want What Ability to claim from?* Core Support

If Core Support what line item?

Social and Community Participation

If Capacity Building what line item?

THIS PERSON AND/OR ORGANISATION HAS CONSENT TO DISCUSS OR RECEIVE INFORMATION REL ATED TO: All my information regarding What Ability supports OR I CHOOSE TO SELECT THE FOLLOWING: https://staging.onboardify.au/client/form/list/all/7

If you are completing this form on behalf of a participant, please indicate

My personal information (eg name, DOB, NDIS number, email)

My NDIS information (eg Assessments and reports, goals, plan fund ) Other

PLEASE SPECIFY IF OTHER:

PLEASE TICK THE RELEVANT BOXES BELOW TO INDICATE THE PURPOSE OF YOUR CONSENT FOR US TO SHARE THIS INFORMATION

My NDIS Access request

To prepare/review/implement my NDIS plan

To review a decision made by the What Ability (eg incident management in WhatAbility care)

To discuss or receive feedback about an enquiry, complaint or feedback

To discuss or receive feedback about an incident or BSPs

To discuss a provider payment query or provider quote

To discuss an Administrative Appeals Tribunal request

To discuss compensation I am or will be receiving other

PLEASE SPECIFY IF OTHER:

Part C: Third Parties ( Person and/or organisation 2 and/or family group)

Third Party Consent

Third Party consent is obtained so information on your support plan can be communicated to family members, carers, other providers and relevant government agencies. For example, you can agree to the third party making a request on your behalf for: a plan review where you have a change in circumstances a review of a decision made by the What Ability Assistive Technology, Home Modi cations or other funded supports, or making arrangements or providing information for a plan being developed https://staging.onboardify.au/client/form/list/all/7

You can choose to provide your consent for ALL areas, or use the boxes below to choose speci c areas you wish to provide consent for.

FULL NAME AND/OR NAME OF ORGANISATION 2

THIS PERSON AND/OR ORGANISATION HAS CONSENT TO DISCUSS OR RECEIVE INFORMATION REL ATED TO: Checkbox 1

OR I CHOOSE TO SELECT THE FOLLOWING:

My personal information (eg name, DOB, NDIS number, email)

My NDIS information (eg Assessments and reports, goals, plan funds) other

PLEASE SPECIFY IF OTHER:

Part D: Third Parties ( Person and/or organisation 3 and/or family group)

Third Party Consent

Third Party consent is obtained so information on your support plan can be communicated to family members, carers, other providers and relevant government agencies. For example, you can agree to the third party making a request on your behalf for: a plan review where you have a change in circumstances a review of a decision made by the What Ability Assistive Technology, Home Modi cations or other funded supports, or making arrangements or providing information for a plan being developed. You can choose to provide your consent for ALL areas, or use the boxes below to choose speci c areas you wish to provide consent for.

FULL NAME AND/OR NAME OF ORGANISATION 3

THIS PERSON AND/OR ORGANISATION HAS CONSENT TO DISCUSS OR RECEIVE INFORMATION REL ATED TO: Checkbox 1

OR I CHOOSE TO SELECT THE FOLLOWING: https://staging.onboardify.au/client/form/list/all/7

My personal information (eg name, DOB, NDIS number, email)

My NDIS information (eg Assessments and reports, goals, plan fund ) other

PLEASE SPECIFY IF OTHER:

PLEASE TICK THE RELEVANT BOXES BELOW TO INDICATE THE PURPOSE OF YOUR CONSENT FOR US TO SHARE THIS INFORMATION

My NDIS Access request

To review a decision made by the What Ability (eg incident management in What Ability care)

To discuss or receive feedback about an enquiry, complaint or feedback

To discuss or receive feedback about an incident or BSPs

To discuss a provider payment query or provider quote

To discuss an Administrative Appeals Tribunal request

To discuss compensation I am or will be receiving other

PLEASE SPECIFY IF OTHER:

FIRST NAME https://staging.onboardify.au/client/form/list/all/7