Consent to share your information Please use this form to give your permission (consent) for the National Disability Insurance Agency (NDIA) to share your National Disability Insurance Scheme (NDIS) information with a person or an organisation who you choose. For example you might want to share some or all of your NDIS information with a family member who helps you to make decisions or with a provider you use regularly. 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 or emailing us at [email protected]. You can also contact us if you want someone to do things for you with the NDIS or make decisions on your behalf. You can give your consent to share information if you are an applicant, a participant, a child representative, plan nominee or legally appointed decision maker for an applicant or participant. When we say applicant, we mean someone who is applying to the NDIS. We will only share your personal information if you have given us consent to 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 to us sharing information on your behalf. Part A: Applicant/participant detailsFull nameDate of birth (DD/MM/YYYY)NDIS numberContact phone numberContact 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). Full nameDate of birth (DD/MM/YYYY)Contact phone numberContact Email Relationship to applicant/participante.g. child representative, plan nominee, legally appointed decision makerEmployee number or logon (if you are completing this form as part of your job)Part C: Provide consent Please complete the details of who you want to share your information with. 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. 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 NDIA giving information about me (or the participant/applicant I am representing who is identified in Part A of this form), to the following people and/or organisations: 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 We will share all of your information with the person or organisation you have chosen, unless you let us know what you don’t want us to share.Information you don't want us to share If any, please choose the information you don’t want us to share:My Personal information My name, date of birth, NDIS participant number and NDIS participant status My address, email and phone number Details about my carers Details about my informal supports Details about my service providers My NDIS information Assessments and reports the NDIA holds about me My NDIS application form The outcome of my NDIS application If I am found eligible for the NDIS, confirmation of when my first plan is approved A copy of all parts of my current NDIS plan A copy of my current NDIS plan’s goals and aspirations A copy of my current NDIS plan’s funding and support Who my NDIS contact is and how to contact them A copy of all parts of any previous NDIS plans A copy of any previous NDIS plan goals and aspirations A copy of any previous NDIS plan funding and support Other. Please tell us below: Any other information If so, please tell us what this information is below: Other informationWhy do you want us to share your information? – To allow my NDIS Support Coordinator to fully assist me.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.SignatureNameDate (DD/MM/YYY)
