Fill out & sign digitally

NDIS Consent to Share Information

This form authorises the Provider named below to exchange information with the NDIA, Plan Management Providers, and third parties to coordinate supports.

1 Participant Details (The Child)

Full Name

Date of Birth

NDIS Number

Address

1a Nominee / Child Representative

Nominee Full Name

Relationship to Participant

Nominee Email

Nominee Phone

2 Provider Details (Recipient)

Support Coordinator Name

ABN

Phone Number

Email Address

3 Authority to Act

I, the Participant (or Authorised Representative), hereby grant permission for the Provider named above to act as my Support Coordinator. I authorise them to communicate with the NDIS, my Plan Management Provider, and other service providers to coordinate my supports.

4 Plan Management Authority

I explicitly authorise my Plan Management Provider to disclose the following financial information to the Provider named above:

Current NDIS Plan Budget, Remaining Balances, and Plan Dates. Invoice payment status, history, and remittance advice. Breakdown of Capacity Building and Support Coordination funds.

5 Third Party Consent

I consent to the Provider named above exchanging information (including reports, assessments, and care plans) with:

National Disability Insurance Agency (NDIA) Allied Health Professionals (OT, Speech, Psych) Service Providers (Core Supports) GP & Medical Specialists Schools / Education Providers Local Area Coordinator (LAC) / ECEI Partner

Other Agency / Professional (Please Specify):

Authorisation & Signature

I understand that I can revoke this consent at any time by contacting the Provider in writing. This consent is valid for the duration of my Service Agreement or until revoked.

Signing As: Participant Nominee / Child Representative

Signature (Draw Below)

Name of Signatory (Print Name)

Date Signed

Compliant with the Privacy Act 1988 (Cth) and NDIS Code of Conduct.