Consent For The NDIA to Share Your Information
Please read and sign this form to give the National Disability Insurance Agency (NDIA) permission to share your information on your behalf. The information we will share will depend on the permission you give us on this form. For example, you can agree to us sharing information to a third party about:
• you
• your plan or your funded supports
• your medical reports held by us
• your NDIS plan being developed
• requests asking us to review a planning decision we have made.
You do not have to give your permission if you do not want to share your information. If you give us permission and then decide that you don’t want us to share your information anymore, you can withdraw your consent by contacting us. You can do this in writing or verbally.
We will not share your personal information to anyone unless you have given your permission or the disclosure of your information is required or authorised by law.
Note: You can provide your consent to share your information with up to three people and/or organisations on this form.
Form
Part A: Participant details
Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please complete this section about the participant you are representing.
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 a participant:
- under 18 years for whom you have parental responsibility, or a child representative
- 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 confirmation that you are authorised to represent the participant and to verify your identity.
Please mark the relevant box below to indicate your relationship to the participant
☐ Child representative
☐ Plan nominee
☐ Legally appointed decision maker
Part C: Third party details and consent
I consent to the NDIA giving information about me (or the participant I am representing who is identified in Part A of this form), to the following people and/or organisations.
Note: In this part, you can provide the details of up to three people and/or organisations.
3.1 Person and/or organisation 1
3.1a Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation
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
☐ The assessments and reports held about me by the NDIA
☐ My NDIA Access Request Form
☒ 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
☒ My NDIS Contact
☒ A copy of all parts of my previous NDIS Plan/s
☒ A copy of my previous NDIS Plan/s Goals and Aspirations
☒ A copy of my previous NDIS Plan/s funding and support
Any other information
☐ If so, please specify what this information is below:
______________________________________________
3.1b Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information
☐ My NDIS Access request
☐ To prepare my first NDIS plan
☐ To review my NDIS plan
☐ To implement my NDIS plan
☐ To review a decision made by the NDIA
☐ To discuss an enquiry, complaint or feedback
☐ To discuss a provider payment query
☐ To discuss a provider quote
☐ To discuss an Administrative Appeals Tribunal request
☐ To discuss compensation I am or will be receiving ☐ Other. Please specify below:
__To provide Plan Management services_______________.
3.1c Please mark the relevant box below to indicate the length of time you are providing the consent for
☒ Ongoing
☐ For the duration of my current NDIS plan
☐ For a set time ending (DD/MM/YYYY):
☐ Once only
| Until we receive written authorization or cancellation |
Part D: Your declaration
Please note: NDIS participants’ aged 18 and over have other options instead of signing this consent form.
- If you are unable to sign in Part D, you may provide verbal consent to the NDIA, or
- You can direct someone aged 18 and over to sign (your ‘delegate’) in the presence of a witness.
If you direct a delegate to sign on your behalf, your delegate and witness needs to complete Part E. Otherwise, please sign, below.
By signing this consent form (please mark each box below):
☒ I understand I can obtain 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 (ndis.gov.au/privacy).
☒ 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.
If you are not the participant, please mark the relevant box below to indicate your relationship to the participant
☐ Child representative
☐ Plan nominee
☐ Legally appointed decision maker (please provide the NDIA with details of this appointment if not already provided).