Consent for a third party to act on your behalf Please use this form to give your permission (consent) to another person or an organisation (third party) to do things for you with the NDIS. There are 4 parts to this form (A, B, C, and D). Depending on your situation, you will not have to complete each part. We have provided instructions for you throughout the form. You don’t have to use this form to give your consent. You can let us know over the phone by calling 07 4100 9091. You can give your consent for someone to act on your behalf if you are an applicant, a participant, a child representative, a plan nominee or legally appointed decision maker for the applicant or participant. When we say applicant, we mean someone who is applying to the NDIS. We will only let another person or organisation do things for you with the NDIS if you have given us consent or if we are required or authorised to disclose your information by law. You can take away your consent at any time. You can let us know by mail, email, in person or over the phone that you no longer consent for a third party to do things for you with the NDIS.Forms Part A: Applicant/participant details Please complete Part A with the details of the person who is giving consent.Full name Date of birth (DD/MM/YYYY) NDIS number Contact phone number Contact Email If you are the applicant or participant, go to Part C. If you are a child representative, plan nominee or other legally appointed decision maker, complete Part B then Part C.Part B: Child representative, plan nominee, legally appointed decision maker details Please provide your details in this section if you are completing this form on behalf of the applicant or participant: under 18 years for whom you are a child representative, or for whom you are a plan nominee, or for whom you are a legally appointed decision maker (for example, a guardian). The NDIA may ask you to provide information to confirm you are authorised to represent the participant or applicant and to verify your identity.Full name Date of birth (DD/MM/YYYY) Contact phone number Contact Email Relationship to applicant/participante.g. child representative, plan nominee, legally appointed decision maker Employee number or logon (if you are completing this form as part of your job) Part C: Third party details and consent Details of who you want to give consent to Please complete the details of the persons/organisations you want to give consent to act on your behalf below. You can provide the details of up to two people and/or organisations. If there are more people or organisations you want to give consent to, you can include them as a list when sending this form back to us. I consent to the below persons/organisations to act on my behalf: Organisation name – Rhino Support Coordination Phone – 07 4100 9091 Email – [email protected] Address – The Regional Business HQ, Office 13, 20B Quay Street, Bundaberg, QLD, 4670 Relationship to applicant/participant – NDIS Support Coordinator What would you like the above person/organisation to do on your behalf?Please mark the boxes that apply to you. To make an access request To request review of your plan, including due to change in circumstances To request a review of a decision made by the NDIA To send us information we ask for if we do an agency initiated plan review To assist with making requests for Assistive Technology, Home Modifications, or other specific supports To make a complaint for you and to talk to the NDIA about the complaint To make administrative changes to your NDIS record such as updating your contact details To update your bank account details in your NDIS record Other. Please tell us below: Other Be able to discuss, add, remove, modify services, request Service Agreements or details, cancel, suspend or cease services, request reports or any other information with engaged service providers.How long are you providing consent for? Until further notice Until a set date One time only What is the date? Part D: Your declaration This part needs to be signed by whoever completed this form. This may be the participant/applicant, or child representative, plan nominee or legally appointed decision maker. I confirm that: I understand I can get further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. You can find this information on the NDIS website. I understand I have given the NDIA consent to give information about me to the third party or parties I have listed at Part C on this form so they can take the identified action/s on my behalf. I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time. I confirm the information provided in this form is complete and correct. I understand giving false or misleading information is a serious offence. I understand this information is protected by law and can only be given to someone else where Commonwealth law allows, or requires it, or where I give permission. You can find out more about how we collect, use and disclose your personal and sensitive information on our website (>a href="ndis.gov.au">ndis.gov.au). Select ‘About’, then select ‘Policies’, then ‘Freedom of Information’, then ‘Privacy’ from the menu on the right.Please upload your NDIS Plan (If applicable)Accepted file types: pdf, doc, docx, Max. file size: 50 MB.SignatureName Date (DD/MM/YYY)
