1). PARTICIPANT DETAILS




As specifically listed on NDIS Plan/Diagnostic Letters i.e. Autism Level 2, Schizophrenia
Please provide an additional information that may be of benefit to your therapist

2). KEY CONTACTS


Emergency Contact must be different from Key Contact



3). SERVICE DELIVERY PREFERENCES

*Currently servicing Metro Melbourne, Metro Sydney, Brisbane, Gold Coast, Canberra and Newcastle*


4). NDIS Plan Details

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5). Assessment/Therapy Services Required

Services - Quote Estimator

Access Telehealth charges the standard NDIS rate of $193.99 per hour for services and $193.99 per hour for travel costs as per the 2022-2023 NDIS Price Guide.

How many hours are you requesting for services (including travel and reporting)?

Please specify the total budget required until the end of plan. # Please note - to make an allowance within the total budget for incidentals:  e.g testing, research, communications, and report writing to meet NDIS standards #

Access Telehealth charges the standard NDIS rates per hour for travel in areas  MMM1 – 5 price guide 2022 - 2023


Vaccination Status (Covid):

Access Telehealth endeavors to eliminate or minimize the risks of COVID-19 as far as reasonably practicable. Access Telehealth identifies that under Workplace Health and Safety (WHS) guidelines, the COVID-19 vaccine is not a reasonably practicable control measure to manage the risks of COVID-19 in the workplace.  Our risk assessment meets the Access Telehealth WHS duties by applying other controls to address the risk of COVID-19. 

Reference: https://covid19.swa.gov.au/covid-19-information-workplaces/industry-information/general-industry-information/vaccination



6). CONSENT

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Schedule of Supports

Access Telehealth agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports

Service requirements  e.g  Assessment or Consults

Rate per hour

Units/hours

Total

Occupational Therapy

Initial Consult(Including Travel, initial consult, review of referral, liaison and preparation. )

$193.99

3

$581.97

Please allow for

Travel, Report Writing, Liaison and Communication, Research etc


Total Budget

$581.97


The supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a Participant’s NDIS supports) are the responsibility of  You, and are not included in the cost of the supports. Examples include entrance fees, event tickets, meals, etc.

Access Telehealth charges the standard NDIS rates per hour for travel in areas  MMM1 – 5 price guide 2022 - 2023

Other Supports

Access Telehealth agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports

Service requirements  e.g  Assessment or Consults

Rate per hour

Units/hours

Total

Speech Pathology

Initial Consult (Including initial consult, review of referral, liaison and preparation. )

$193.99

2

$387.98

Please allow for

Report Writing, Liaison and Communication, Research etc


Total Budget

$387.98


Access Telehealth agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports

Service requirements  e.g  Assessment or Consults

Rate per hour

Units/hours

Total

Psychology

Initial Consult (Including initial consult, review of referral, liaison and preparation. )

$222.99

2

$445.98

Please allow for

Report Writing, Liaison and Communication, Research etc


Total Budget

$445.98


Access Telehealth agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports

Service requirements  e.g  Assessment or Consults

Rate per hour

Units/hours

Total

Dietetics

Initial Consult (Including initial consult, review of referral, liaison and preparation. )

$193.99

2

$387.98

Please allow for

Report Writing, Liaison and Communication, Research etc


Total Budget

$387.98


Access Telehealth agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports

Service requirements  e.g  Assessment or Consults

Rate per hour

Units/hours

Total

Mental Health Social Work

Initial Consult (Including initial consult, review of referral, liaison and preparation. )

$193.99

2

$387.98

Please allow for

Report Writing, Liaison and Communication, Research etc


Total Budget

$387.98


What Are Our Fees

Access Telehealth will invoice for services in accordance with the NDIS Price Guide 2022-2023. We monitor any changes to the NDIS Price Guide and will make any changes when required. 

Provider Travel is billed in accordance with the NDIS Price Guide 2022 -2023 and follows the Modified Monash Model. This model categorises all Australian locations as urban, regional, or remote. We will assist participants to minimise the travel costs where possible.

Ranging from MMM1 (city)  – MMM7 (very remote)

MMM1 - MMM3 : up to 30 minutes travel

MMM4 - MMM5 : up to 60 minutes travel

MMM6 - MMM7 : specific arrangements must be made

(where the therapist’s journey is the last appointment of the day, they can claim a return trip fee)


Access Telehealth Responsibilities

Access Telehealthagrees to:

I. review the provision of supports at least annually with the participant;

II. once agreed, provide supports that meet the participant’s needs at the participant’s preferred times;

III. communicate openly and honestly in a timely manner;

IV. treat the participant with courtesy and respect;

V. consult the participant on decisions about how supports are provided;

VI. give the participant information about managing any complaints or disagreements, cancellation policy;

VII. listen to the participant’s feedback and resolve problems quickly;

VIII. give the participant the required notice if Access Telehealth needs to end this Service Agreement (see ‘Ending this Service Agreement’ below for more information);

IX. protect the participant’s privacy and confidential information;

X. provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013(NDIS Act) and rules, and the Australian Consumer Law;

XI. keep accurate records on the supports provided to the participant; and

XII. issue regular invoices and statements of the supports delivered to the participant as per the NDIA’s Terms of Business for Registered Providers.

Responsibilities of You

Youagree to:

I. inform Access Telehealth about how they wish the supports to be delivered to meet the participant’s needs;

II. treat Access Telehealth with courtesy and respect;

III. talk to Access Telehealth if the participant has any concerns about the supports being provided;

IV. give Access Telehealth minimum of 48 hours’ notice if the participant cannot make a scheduled appointment, noting that if the notice is not provided by then, Access Telehealth cancellation policy will apply;

V. give Access Telehealth the required notice if the participant needs to end this Service Agreement (see ‘Ending this Service Agreement’ below for more information); and

VI. let Access Telehealth know immediately if the participant’s NDIS plan is suspended or replaced by a new NDIS plan, or the participant stops being a participant in the NDIS.

Payments  -  Access Telehealth will seek payment for their provision of supports after  You confirm satisfactory delivery.

Cancellation Policy

Out of consideration and respect for Access Telehealth’s time, Youmust provide Access Telehealth with at least 48 hours’ notice of the cancellation of any supports. For cancellation of weekend supports, Youmust notify Access Telehealth by 5:00pm on the previous Thursday. Failing to do so, will incur the full rate per hour. Please be aware that multiple cancellations or no shows will be recorded on the participants profiles – this information may be retrieved by NDIA. Where Access Telehealth cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party.

Thank you for taking the time to fill out and complete our referral form . Please do not hesitate to call on 1300 886 077.


Thank you for the referral

Ph: 1300 886 077   ndis@accesstelehealth.com.au

Occupational Therapy/ Speech Pathology/ Psychology/ Counselling/ Mental Health Social Work /Dietitics

Access Telehealth Referral Form V16.   Date created: 16.11.2020.   Date revised: 14/08/2023