NDIS New Patient Information Form

Patient Details

Date *

First name *

Last name *

Phone Number *

Date of birth *

Home address *

Postcode *

Email address *

Patient Contact Person (if not patient)

Patient Contact Person Phone number

Patient Contact Person Relationship to Patient

NDIS listed diagnosis *

Who referred you to Healthy Bodies Physiotherapy? *

Support co-ordinatorOther

Support Co-ordinator Name *

Support Co-ordinator Phone Number *

Support Co-ordinator Email *

Please specify *

Is an interpreter required for your appointments? *

YesNo

Please specify language *

NDIS Details

Plan Type *

Self ManagedPlan ManagedAgency Managed

NDIS No. *

NDIS Plan Start Date: *

NDIS Plan End Date

Next Plan Review Meeting Date

What therapy are you looking for? (select multiple if required) *

PhysiotherapyOccupational TherapyDietitianExercise Physiology

To book the initial assessment *

Please have the NDIS manager contact the patient directlyPlease have the NDIS manager contact the support co-ordinatorPlease have the NDIS manager contact the appropriate contact person for the patient

Please Specify *

Plan Management Agency

Email address for invoicing *

NDIS Goals

Upload NDIS plan here

Browse

Supporting documents (medical letters, previous therapy reports)

Browse

Assessment / Care Needs

Is this referral for ongoing therapy (capacity building therapy)? *

YesNoUnsure

Are assessments and or reports required? *

Functional Capacity Assessment (FCA)Specialist Disability Accomodation Assessment (SDA)Supported Independent Living Assessment (SIL)Assistive Technology Assessment End of Plan Report Minor Home Mods (e.g: rail installation, portable ramps, rubber door ramps)None

Date assessment/report due *

Breakdown of Funding Periods for Services

Start/Finish Date for each funding period *

Amount allocated for this plan, for the requested service: *

Is this referral urgent? *

Yes No

If other, please specify why *

As part of our Healthy Bodies Physiotherapy Safety Protocol, we need to complete a risk assessment before attending any appointments, please provide contact details for someone who can advise on the premises contact details for a phone assessment with our NDIS Manager. *

Phone Number for Risk Assessment *

CLIENT SERVICE AGREEMENT AND INDEMNITY

Definitions

In this Agreement the term "You" means the person signing this agreement as the client and the terms "Us" or "We" means Healthy Bodies Physiotherapy Victoria.

Release & Indemnity

You agree that you have disclosed to us your relevant medical history and any conditions or ailments, which could impact on your ability to participate in treatment, exercise or do activities advised by us. This includes but is not limited to a history of or the presence of conditions or ailments such as high blood pressure, low blood pressure, arthritis of any nature, ligament and/or tendon injury or repair, a heart condition of any nature, heart surgery of any nature, epilepsy, immune system condition, hepatitis, cancer, osteoporosis or any other condition or ailment which could impact on your ability to be treated or exercise safely.

You acknowledge and agree that the treatment program we design for you will be based on the medical history that you disclose to us. You release us from any liability for death or personal injury which, arises from your participation in a program with us where such death or personal injury is contributed to or arises from any condition or ailment or any relevant medical history which you have failed to disclose to us. You agree that this release binds your heirs and successors and that it may be pleaded by us as a complete bar to any legal proceedings by you or your heirs and successors. You indemnify us for any damages, costs or expenses of any nature which we may incur as a result in you, heirs or successors commence legal proceedings in breach of this agreement.

Cancellations

You agree to give us a minimum of 48 hours notice of any cancellations. If you fail to give us this minimum notice, you may be charged a cancellation fee. To avoid any fees this must be done within our hours of operation (Monday to Thursday 7am-8.30pm, Friday 7-6pm, Saturday 7-12pm). We are closed on public holidays.

Privacy

Your personal and medical information will be kept private and protected by industry standard security software. When necessary to ensure you the best possible health outcomes we will provide information to other medical professionals/agencies involved in your care.

Payment

In the event a third party or insurer does not make payment for the services you are provided, you acknowledge full responsibility for payment of these services.

All accounts outstanding for more than 7 days will attract an administration fee of 10% per week.

Costs of Recovery

In the event of an overdue account, you may be liable for any additional costs incurred in recovering the debt, including but not limited to administration fees, legal costs, and third-party debt collection fees. By signing this form, you acknowledge and accept responsibility for all costs associated with the recovery of unpaid fees.

Signature *

Clear

Date Signed *

Please note, we are not a crisis service. If you require critical care, please call 000 immediately.