Form Role

Who is completing this form?*

I am an NDIS ParticipantI am a Parent, Nominee, Guardian or Authorised Representative of an NDIS Participant

Service Agreement Consent*

Yes, I would like Plan Management services to be provided by Synergy West Plan Management

Preferred Contact Method (select an option)*
Phone CallSMS/TextEmailPostEasy English

How Did You Hear About Us?

Social MediaGoogle SearchWord of MouthSupport Coordinator ReferralOther

Is there a Plan Nominee, or someone other than the Participant, who is responsible for the Plan and has legal authority to make decisions on behalf of the Participant? If YES, please provide details below. *

YesNo

Allow your Plan Nominee/Authorised Representative access to:

Online DashboardMonthly Statements

Do you have a Support Coordinator?*
YesNo

Allow your Support Coordinator access to:

Online DashboardMonthly Statements

Consent to Share: By ticking the box on the sign-up page, you agree to the terms and conditions as outlined in this Service Agreement. The Participant agrees to share their NDIS plan and information with Synergy West Plan Management, as well as the Participant’s Support Coordinator, Local Area Coordinator (LAC) and NDIA Planner. If you do not understand any section of this agreement, please talk to a family member your nominee / representative / guardian or contact info@synergywest.com.au to obtain further clarity before acknowledging consent. If you wish to provide Consent to Share information with other providers or contacts, please select below:

Authorised RepresentativeAllied Health Providers (ie OT/Physio etc)

Please attach a copy of your NDIS Plan

Invoice Approvals: When we receive invoices to pay from your NDIS plan, how do you wish to review them? Please choose one of the below methods for reviewing/approving your Support Providers’ invoices:*

I wish to have two days to review and approve each invoice before it is paid. If I do not check and approve/decline the invoice during this time, the invoice will be automatically paid once the two days has passed.I wish to have all invoices paid automatically once they are received by Synergy West Plan Management. I will keep Synergy West Plan Management up to date with any changes in my expected supports and providers. I will check my monthly NDIS budget statement to ensure invoice payments are correct and I will contact Synergy West Plan Management if I have any questions or concerns.

Agreement Acknowledgements *

I am the NDIS Participant named above, or I am the Plan Nominee or legal representative of the NDIS Participant named above and I am authorised to submit this Service Request. The details I have provided above are true and correct.

I agree to Synergy West Plan Management's Terms & Conditions.
View Terms & Conditions

Your Signature

Today’s Date

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