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NDIS Order Form
NDIS Form
Complete and submit this form and then continue with your order.
Participant Details
Participant First Name
*
Participant Last Name
*
NDIS Number
*
Date Of Birth
*
Nominee Name
*
Email
*
Phone
*
Participant Address
*
Suburb
*
State
*
-- Please Select --
New South Wales
ACT
Queensland
Victoria
South Australia
Western Australia
Northern Teritory
Tasmania
Postcode
*
NDIS Plan
My NDIS Plan is:
*
-- Please Select --
Agency Managed
Plan Managed (please allow time for your Plan Manager to process your payment.)
Is the support needed because of your disability?
*
Yes
No
Will this support assist you in working towards your plan goals?
*
Yes
No
*Refer to your NDIS plan for details.
Are the costs for this support considered to be value for money?
*
Yes
No
Is the support considered to be effective, beneficial and good practice?
*
Yes
No
Is this reasonable for your informal supports?
*
Yes
No
(i.e. Family, Friend, Advocate etc.)
Is the NDIS the most suitable form of funding for this support?
*
Yes
No
(i.e. Department of Health, Education, Veteran Affairs etc.)
*Please note, If the NDIA decides that the support you are receiving is not considered reasonable and necessary, you may be responsible for covering the costs using your personal funds.
Signature
*
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Plan Managers Name
*
Plan Managers Email
*
Plan Managers Phone
*
I would like payment for this order to be taken from:
*
-- Please Select --
Assistive Technology
Core Supports / Consumables
Details of Person Submitting This Form
Full Name
*
Email Address
*
Terms & Conditions
*
I agree to allow the Sensory Store, a registered business name of Nepean Area Disabilities Organisation (NADO) to process a claim for products as per my order.
This NDIS form constitutes a Service Agreement between the participant and the Sensory Store, a registered business name of Nepean Area Disabilities Organisation.Â
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