Service Agreement

Form22. Service Agreement

Part 1Step 1 of 3

Doc No: Form22 Version No: 01

Version Date: 03/08/2023

Service Agreement

Participant Name

Date of Birthday (DOB)

NDIS Number

and is made between:

Participant Name/ Participant’s representative:

Date of Birthday (DOB)

NDIS Number

and the Provider
Kangaroo Disability Services

ABN:

NDIS Provider No:

This Service Agreement will commence on (please select date)

End Date

This Service Agreement is made to provide support under the Participant’s National Disability Insurance Scheme (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 pursuing their goals, planning and delivering their supports.

Is this participant subject to Section 73 G of the NDIS Act? (If yes please refer to the Provider responsibility section for further information)

Note: Section 73G of the NDIS Act refers to a participant who is provided with personal support in their own home may experience a level of risk if those supports are provided by the same individual NDIS worker for an extended period of time. This risk is likely to be greater where the NDIS participant lives alone.

Is this participant subject non-verbal or requires language translation services? (If YES complete the Mode of Communication section of the Participant Risk Assessment)

Schedule of Supports

Service fees are based on the price limit set out in the NDIS Pricing Arrangements and Price Limits Guide. The Provider agrees to provide the following support items:

Description

NDIS Item number

Unit

Price

Quantity and Frequency

Comments

Please click Add to add more

Hourly rates are applicable to the progress reports for the relevant support item in the NDIS Plan. In some circumstances, we may be able to charge a fee for services and support provided to the participant including transport or travel costs.

I agree that travel costs could be claimed.

Description

NDIS Item number

Unit

Price

Quantity and Frequency

Comments

Please click Add to add more

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

Workers with the same qualifications and experience will be assigned as a delegate to ensure the same level of support is provided to the participants and adequate training will be provided to them.

Participant’s Rights/Responsibilities:

• Confirming service schedules: Kangaroo Disability Services endeavors to confirm service schedules either by email or SMS. However, it is your responsibility to be aware of the scheduled services.

• Cancellation Policy: Please be advised that we ask you to give us at least 7 days (7) notice via email, telephone, or SMS for service cancellation. If a service is cancelled after trading hours in the day prior to the service delivery day, or if the participant is not present on the service day, a fee will be claimed from your NDIS plan. If less than 7 days (7) notice is provided to the Kangaroo Disability Services for a cancellation, the participant will be charged up to 100% of their scheduled services. If a cancellation is made by Kangaroo Disability Services for reasons such as lack of staffing level or qualifications/experience, the schedule of support in place cannot be claimed because of this.

• Complaints: Participant or their carer can make a complaint to Kangaroo Disability Services either anonymously, via email or in person. Upon request, Kangaroo Disability Services can provide a copy of the Complaint Management policy and procedure or it may be accessible through the provider’s website. Initially, the participant can contact Kangaroo Disability Services or the Quality and Safeguards Commission if they want to make a complaint. Furthermore, if under any circumstances, the participant is not satisfied with the services and outcome of the complaint, it is their right to lodge a complaint with NDIS Complaint Commissioner on: 1800 035 544.

• Advocate: It is the participant’s right to ask for an advocate if they require. Kangaroo Disability Services might appoint an advocate if the participant is not in the position to appoint one themselves but requires/wants this type of support.

• Service Fee: Fees are payable at the time of appointment if the participant’s NDIS Plan is self-managed, or nominee managed fund. For all other funds, invoices are to be paid in 7 days. Different methods of payment are accepted by the Kangaroo Disability Services including cash, BPAY, direct debit from the credit card or account provided by the participant. If the incurred cost is not covered by NDIS Plan either due to lack of funds or lack of support, the participant is liable for the charges.

• Payment claims for self-managed or plan-managed participants:

The Participant has nominated

to manage the funding for supports provided under this Service Agreement. After providing those supports, the Provider will claim payment for those supports from the above-mentioned party.

Emergency Preparedness

Kangaroo Disability Services will develop an emergency response plan to respond to any unplanned event that can cause:

• Deaths; or
• Significant injuries to employees or occupants; and/or
• Shut down the business; and/or
• Disruption to operations; and/or
• Physical or environmental damage

Our operations Manager or Supervisor will ensure that there is an Emergency Evacuation diagram for each site and an Individual Disaster Management Plan, using Form33. Participant Disaster and Risk Assessment is created.

For your peace of mind, all our support workers are trained on how to respond in case of an emergency, and they will receive a copy of your individual disaster management plan so that they are fully aware of your health condition and the required action plans in case of an emergency. Apart from that, all possible emergency scenarios are mentioned in the table below and the required supports are mentioned to ensure that we are providing support and services without any disruptions. For more information about our emergency response, please refer to the provided

Form82. Emergency Response Plan and Form33. Participant Disaster and Risk Assessment.

Emergency

Support provided to the participants BEFORE an emergency

Support provided to the participants DURING an emergency

Support provided to the participants AFTER an emergency

Please click Add to add more

Changes to this Agreement

If the participant or Kangaroo Disability Services wants to change this agreement, they shall make any changes they have talked about and agreed to in writing. The written changes should be dated and signed by the participant and Kangaroo Disability Services.

Providers' Responsibility for participants who are subject to section 73G of the NDIS Act requirements.

It is the provider’s responsibility to document the assessment of the participant’s risk factor using Form27. Initial Assessment and Support Plan, Form33. Participant Disaster and Risk Assessment and Form 32. Participant Home Risk assessment.

A copy of the assessments will be provided to the participant and another copy should be kept by the Provider in their file. If the participant wishes not to receive a copy of the assessment and Service Agreement, this will be recorded on the Service Agreement.

The assessment will be reviewed every year or when the participant’s circumstances change. If there is any update on the assessment, a copy of the new assessment will be provided to the client and a copy will be kept by the Provider in their folder.

It is the provider’s responsibility to mention the rights and responsibilities of the participant and the provider in the Service Agreement.

Using the Human Resource Management process will assist the provider to ensure that the participant’s support worker has been screened.

Participants who are subject to this requirement will be registered on Form56. High-Risk Participant Register, and they will delegate some specific support workers to those who are registered on this form. The level of risk for each participant will be determined using the consequence rating table from the participant risk assessment.

The below table sets out to indicate which risk level the participant is categorised as and the frequency of communication needed to be made to them.

Participant Risk Level Communication

Participant Risk Level Communication

Communication with the Participant
Participant Risk Level	Feedback	In-person Welfare Check (Minimum)	Welfare Check via Phone
Low Risk	Quarterly survey	3 months to 4 months	Monthly
Medium Risk	Quarterly survey	1 month to 3 months	Fortnightly
High Risk	Quarterly survey	2 weeks to 1 month	Weekly

For participant’s who are subject to this requirement, the implementation of the services mentioned in their services will be reviewed every three months by the Operations Manager and should be by someone other than the support workers.

The Operations Manager will supervise and monitor the performance of the support workers through a face-to-face interview at the participant’s home whilst the support worker is not present to ensure their performance is consistent with the agreement and the participant’s safety and wellbeing at least every 3 months or when suspicious of any harm to the participant.

The Operations Manager will provide a report to all key personnel regarding the care and skill with which personal support is to be provided to the participant by the support worker after every visit to the participant’s home or if there is any complication in service provision.

Information Security and Access

Personal Information: Information obtained during your service provision period will be treated as confidential and secure information except in several circumstances as follows:

It is required by Law/Court
You have provided consent to:
1. Provide a written report to another agency
2. Discuss the details of materials with another person

Workers shall provide progress reports to the participant and NDIA outlining plan objectives and goals and if those are met.

Information Security and Access: Personal information and medical information may be collected for service and support provision. During the service provision period, all notetaking, and communications will become a part of the participant’s records. All information will be stored and kept electronically on the participant’s file. If the participant’s personal information is incorrect, you have the right to access and update the records accordingly upon a written request to do so. Personal information will be retained for 7 years.

Ending this Agreement

If either the participant or the service provider wants to end this agreement, each of them agrees to give four (4) weeks’ notice to the other party. If the participant or the service provider seriously breaches this agreement, that notice period will not be required.

Participant Information

Contact Name

NDIS Number

Date of Birth

Phone Number – Day-time

Phone Number – Night-time

Mobile Phone Number

Address

Address Line 1

City

State / Province / Region

Zip / Postal Code

The Service Provider can be contacted on

Contact Name

Phone Number – Day-time

Phone Number – Night-time

Mobile Phone Number

Address

Address Line 1

City

State / Province / Region

Zip / Postal Code

Agreement Signatures:

The participant and the service provider agree to the terms set out above.

Please select one option below

I wish to receive a copy of this agreement.
I wish to not receive a copy of this agreement.

Signature of Participant

Press X to clear the signature

Date

[If signed by a Nominee:]
I confirm that this agreement has been explained to the person receiving the services (Participant) and that they agree to this:

Name of Nominee

Signature of Nominee

Press X to clear the signature

Date

Signature on behalf of Kangaroo Disability Services

Press X to clear the signature

Date

Phone