CONSENT TO EXCHANGE INFORMATION

As your provider of services, there are occasions where we may need to communicate with others about you, the services you receive and your care. By completing this form, you can tell us if you have preferences about how we collect, use and disclose your personal information.

Our Privacy Policy explains how your personal information is collected, used, disclosed and generally handled by 101 Plan Management when you enquire about our services or become a 101 Plan Management customer. A copy of the policy is included with this form, is available on our website, and can be obtained on request at any time.

101 Plan Management collects and stores information (including personal information) as per 101 Plan Management’s Privacy Policy that is essential to provide services, and for reporting and accountability requirements. A record is made by 101 Plan Management which includes your personal details, information about your disability, your funding amounts, your care and support needs, and the services you receive. Your record might also include information about the services and supports you receive from other providers.

Participant's Full Name: *

Date of Birth: *

NDIS Number *

Participant's Residential Address: *

Contact Number:

Email Address:

Nominee / Child Representative Full Name:

Relationship to Participant:

Organisation Name:

Nominee / Child Representative Residential Address:

Nominee / Child Representative Contact No:

Nominee / Child Representative Email Address:

It is important that you tell us about any preferences you may have about your personal information. For example, please let us know:

who you give us permission to contact if we are unable to contact you – for example if you are not home when our staff arrive to provide a service or we are unable to contact you; and
who you give us permission to speak to about the services you receive and to share / exchange your health care information.

101 Plan Management takes privacy seriously. We will take all reasonable steps, so far as is legally permissible, to handle your personal information in accordance with your preferences. If following your preferences would negatively impact on the services we are able to provide, or is contrary to our legal obligations, we will discuss this with you.

101 Plan Management recognises the rights of Participants to access, update and correct their information, as described in detail in the 101 Plan Management Privacy Policy . If your preferences or wishes change over time, please contact us 08 7071 1555 to discuss this.

Nominated person/s

Please list at least one person you give 101 Plan Management to speak to about you and the services provided to you by 101 Plan Management. If you have particular preferences about the type of information that we can share / exchange with a particular person, please write this down.

For example, you might name a person (e.g. your neighbour) that you give 101 Plan Management permission to contact if we are unable to get in touch with you. Alternatively, you may wish to give permission to 101 Plan Management to discuss everything about your services on an ongoing basis with the person you nominate.

(Please do not include Support Coordinators or Service Providers here)

I give permission for 101 Plan Management to communicate and share / exchange information with the person/s whose details I have provided below, when this is necessary for the provision of my care, support and services. I have described any information that I prefer 101 Plan Management does not share / exchange with this person.

Name: (please do not include Service Providers here)

Relationship:

Address:

Phone:

Is there any information 101 Plan Management should not share / exchange with this person?

Name:(please do not include Service Providers here)

Relationship:

Address:

Phone:

Is there any information 101 Plan Management should not share / exchange with this person?

Exchanging your information with third parties

Often we may need to communicate with or share / exchange information as required with third parties to provide you with services. By completing this form, I understand that 101 Plan Management will share / exchange my information with other persons as listed below in relation to my NDIS Plan as required which may include goals, funding and any other information that may be relevant in the provision of services.

Service Provider

Support Coordinator (CoS)

Provider Details

Web Portal Access for CoS to view funding and invoices?

Support Coordinator's Email

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

Service Provider

Provider Details

If you prefer that we DO NOT share / exchange your information with a specific person or organisation, please let us know below.

Person / Organisation

Type of information:

Person / Organisation

Type of information:

Person / Organisation:

Type of information:

Acknowledgement

Please sign below to acknowledge that:

all the information in this form has been explained to you and any questions you have about how 101 Plan Management handles your personal information have been answered; and
you understand, where you have NOT given permission for us to share your personal information to certain people/organisations, that this may impact on the level of support, care and services that we are able to provide to you.

Signatures

If the Participant is under 18 years of age or unable to sign independently, the authorised Nominee or Representative must sign.

You may be contacted by 101 Plan Management to renew consent from time to time. You can update or withdraw consent at any time by notifying 101 Plan Management in writing.

Participant / Nominee / Child Representative Signature *

Draw signature|Type signatureClear

Name of Pariticipant / Nominee / Child Representative *

Signed Date: *

101 Plan Management Representative Signature

101 Plan Management Representative Name

Signed Date:

Save and Complete Later