Rosy Fox

Registration, Service Agreement and Consent Form

All mandatory fields are marked with a red asterisk ( *)

You are free to leave any other fields blank

You must have the following before proceeding? ALL THREE MUST BE TICKED. *

My NDIS NumberMy NDIS PlanPlan Management Funding

Are you an existing client of Rosy Fox, or are you signing up for the first time ? *

New Sign upExisting Participant

Are you transferring from another Plan Manager? *

YesNo

Previous Plan Manager *

Are the funds released? *

Expected Date Funds will be available

**Please note, we are unable to provide services until the funding is available.

Who is completing this service agreement ? *

The NDIS participantThe NDIS participant representativeThe Support CoordinatorThe LAC or NDIS Planner

NDIS Participant Representative Full Name *

Support Coordinator full name *

LAC/Planner full name *

Your Organisation

Your Best Contact Number *

Email address *

Relationship to Participant *

The Participant or their Nominee has given me permission to fill in this agreement *

Participant Details

This Service Agreement is for the following Participant of the National Disability Insurance Scheme:

Please note: we require an email or physical address to send you financial statements. If you do not have a place of residence or email address, type N/A into the relevant fields below and we will contact you or your representative to discuss.

NDIS Participant First Name *

NDIS Participant Surname *

Date Of Birth *

NDIS Number *

Participant Contact Number *

Participant Gender

Participant Email *

Participant Address *

Suburb

State

Postcode

Is the NDIS participant of Aboriginal or Torres Strait Islander descent?

Is there any further information the NDIS participant would like to volunteer, such as cultural requirements or interpreting requirements?

Your Plan Details

Plan Start Date *

Plan End Date *

Service Agreement

This agreement is made between the following parties:

NDIS Participant/Participant Representative Name *

AND

NDIS PROVIDER *

Please see our service agreement terms and conditions here: Link

Signatures

I have read & understood the terms of this service agreement, including the 'Ending this Service Agreement' policy *

Agreement signatures

The Parties agree to the terms and conditions of this Service Agreement.

The Parties agree that they have access to a copy of the Easy Read Complaints, Incidents, Diversity and Inclusion and Privacy and Data Security Policies. These policies are available on our website to download, or at request via email or hard copy.

This service agreement is between Rosy Fox Pty Ltd and:

Name of Participant/ Participant Representative *

Signature of Participant/Participant Representative

Draw signature|Type signatureClear

Agreement Date *

Rosy Fox Representative Signature

Please note: It is not an NDIS requirement to have a signed service agreement to receive plan management services, and therefore you are not required to provide a signature on this form.

If you are not the NDIS participant this agreement is for, you will have the option at the end of this form to save and send the filled in form to the participant for a signature, or submit this form without a signature.

By entering into a service with us, you are also giving your consent to Rosy Fox to collect and utilise your private information solely for the purposes of providing services to you. This can include disclosure of your private information when necessary to external parties, such as your support coordinator or support workers.

If at any time you would prefer NOT to disclose some of your personal information, please complete the attached Consent Form at the end of this service agreement or let one of our friendly staff know over the phone at (03) 8609 3600 or via email to intake@rosyfox.com.au. If you would like more information about how your private information is collected, stored, and accessed by Rosy Fox employees, please ask a staff member for a copy of the Rosy Fox Privacy and Document Security Policy and Procedure – we also have an Easy Read version if you would prefer.

Consent Form

PARTICIPANT (or PARTICIPANT REPRESENTATIVE) INFORMATION

DO YOU CONSENT TO ROSY FOX COLLECTING THE FOLLOWING INFORMATION ABOUT YOU AND YOUR NDIS PLAN ?

Personal information, including name, date of birth, gender, Aboriginal and/or Torres Strait Islander status, contact information, and home address. *

Yes I ConsentNo I Do Not Consent

**Please note, we are unable to provide services if you do not consent to us collecting your name and date of birth.

Evidence related to paying invoices within the intent of NDIS funding where relevant, please note this may include reports from health professionals *

Yes I ConsentNo I Do Not ConsentNot Applicable

Management records, including a participants plan and details of their disability, service agreements, and correspondence. *

Yes I ConsentNo I Do Not Consent

Audio recordings. Please note: The sole purpose of this consent is so we can use audio recordings to verbally obtain consents or confirm agreement to services. *

Yes I ConsentNo I Do Not ConsentNot Applicable

DO YOU GIVE CONSENT TO ROSY FOX TO GIVE THE FOLLOWING PARTIES INFORMATION ABOUT YOU AND YOUR NDIS PLAN?

Your Service Providers (This could include information about budgets relevant to their services, or speaking to them about their invoices) *

Yes I ConsentNo I Do Not Consent

Your LAC, NDIS Planner or any NDIS representative *

Yes I ConsentNo I Do Not Consent

Your Support Coordinator *

Yes I ConsentNo I Do Not ConsentNot Applicable

Support Coordinator Name *

Organisation *

Your Support Coordinators Best Contact *

Is there anyone else you'd like us to share information with? This could be a family member, friend or community support. Please provide their name and best contact.

Full Name:

Best contact:

Relationship to Participant:

BY SUBMITTING THIS CONSENT FORM:
I understand I can obtain further information about how Rosy Fox will handle my personal information
I understand I have given Rosy Fox consent to ask for information about me and share my information with third parties.
I understand I can withdraw my consent at any time.

*

Plan Management Set Up Questions

Below are some general questions about you and your NDIS plan. Giving us this further information will greatly help with managing your budgets and giving you accurate advice and the best service possible. Please note any questions with a red asterisks (*) are required to be answered. All other information is optional.

We're asking you questions, so we want to make sure you know you can ask us questions too! We know the NDIS can be difficult to navigate, as your plan manager we want to work with you to ensure you understand how your NDIS funding can and cannot be spent. For example did you know all invoices for supports provided need to have either the hours of service or hourly rate stated? Did you also know we (unfortunately) cannot pay for massage services or gym memberships? As we said, we are here to help, so if you have any follow up questions about your plan and funding for us please don't hesitate to send us an email or give us a call.

Phone: (03) 8609 3600

Email: hello@rosyfox.com.au

Would you like to disclose your disability? If so, please describe below.

Preferred method of contact

EmailPhonePlease contact my Support Coordinator firstPlease contact my nominated representative first

Contact Name

Phone Number *

Contact Name

Email *

LAC/Planner

LAC/Planner Email or Phone

LAC/Planner Organisation

Support Coordinator

Support Coordinator Email or Phone

Support Coordinator Organisation

As your Plan Manager we process invoices for NDIS participants in accordance with their NDIS funding. It's part of our role to check that invoices we recieve are compliant with NDIS guidelines.

Checking invoices for compliance means making sure invoices have all the right information on them. For example, if an invoice doesn't have an ABN on it we would make sure your provider changed that invoice to add their ABN because that is an NDIS requirement.

Compliance checks also mean we make sure invoices are billed to the correct area of your NDIS plan, that the description of sevices matches what is being billed, and that the services described are funded by the NDIS.

We are not allowed to determine what reasonable and necessary supports are for you. There may be services you recieve that we need to ask questions about because we don't know how they are linked to your disability or what was being provided based on the invoice. If we see invoices for lots of supports all on one day, or repeatedly over a short amount of time, we would need to contact you to check you're reciving those supports.

Having automatic approvals means your invoices will be checked for compliance, and so long as we see no strange patterns with your billing we can pay your invoices automatically. This does leave you at a small risk of providers sending us compliant invoices for supports you haven't recieved, or not sending us invoices at all. Therefore, if you want automatic approvals you must check your monthly statements to make sure you aren't being overbilled or underbilled for supports.

Having manual approvals set means you can check each invoice individually after we've cleared it for compliance, to make sure the services were provided to you.

There are some invoices that cannot be automatically approved, such as Short Term Accommodation or items that are not clearly stated in your plan. In these cases we will be contacted you for your approval, which may cause some delays in invoice payments.

If you manually approve your service providers’ invoices, you will need to monitor the app closely, and approve or decline invoices in a timely manner. Any invoices not approved within 5 days, will be automatically approved for payment (provided they are charged at the correct rate and within NDIA guidelines).

Will you be manually approving your invoices? *

I want to opt out of manually approving my invoices - our plan managers will submit and approve all invoices sent to us by your providers or representatives according to NDIA guidelines. It is important to note that we cannot determine if services have been delivered just from an invoice. We will contact you if we find any false claims or suspect services have not been rendered. Yes - you will receive notifications on our app to approve all invoices that we input into our system to be sent to the NDIA for payment. Please note: while we recommend everyone has manual approvals at least to begin with, you must have the capability to download and use our mobile app to use this option.

Please let us know why you are unable to manually approve invoices

Please confirm your email so we can send you email instructions for manual approvals: *

Would you like access to our app? Please note: If you would like to manually approve invoices you must have access to our app. The app is available on all mobile devices. If you select yes to this option you will receive email instructions on how to set up the app.

YesNo

Please provide your bank details below so any future reimbursements can be processed.

Note: We only use secure online servers, your bank details will not be shared with any third party providers. For more information on our privacy policies please refer to our website. Providing your bank details it optional.

Account Name

BSB

Account Number

Please tick all that apply

Please tick if you would like a copy of this service agreement emailed to you. Please tick if you would like to be emailed a copy of our welcome pack. This includes our privacy policy, incident policy and complaint forms. All these documents are also available for download on our website.Please tick if you would prefer documents to be mailed to you physically. PLEASE NOTE: Here at Rosy Fox we try to minimise the environmental impact of printing. We ask that you only request physical documentation if you are unable to access soft copies.

Have you signed any service agreements with providers? We request this information to make sure we process invoices correct to what you have agreed to. If you have any service agreements, please attach them below.

Browse

Have your NDIS Plan? Upload it Here!

Browse

Please specify:

Are you a robot? *

Save and Complete Later