SERVICE AGREEMENT – Momentum Health Consulting
Purpose of this Agreement
This Service Agreement outlines the supports Momentum Health Consulting will provide, how services are delivered, and the rights and responsibilities of both parties.
Momentum Health Consulting is a non-registered NDIS provider.
We work with:
Self-Managed participants
Plan-Managed participants
NDIA-Managed participants may access services privately, as we cannot invoice the NDIA directly.
Participant Details
Name: ____________________________________
NDIS Number: ______________________________
Address: __________________________________
Phone: ____________________________________
Email: _____________________________________
Plan Details
Plan Type:
☐ Self-Managed ☐ Plan-Managed ☐ NDIA-Managed (private payment only)
Plan Manager (if applicable): __________________________________
Plan Start Date: ________________ End Date: ________________
Participant Goals (NDIS Requirement)
Your supports should help you work toward your goals.
List your goals here:
Services to be Provided
Momentum Health Consulting agrees to provide the following supports:
• RN Health Assessments
• Continence Assessments
• Wound Care
• Catheter Care (IDC/SPC)
• PEG/Enteral Care
• Diabetes Support
• Medication Management
• Functional Capacity Assessments
• Training for Support Workers
• Other: ____________________________________________
Service Delivery
• Supports may be delivered at home, in community settings, or via telehealth.
• Visit frequency is based on clinical need and participant goals.
• Reports, care plans and documentation will be provided when required.
• All services are delivered within the RN Scope of Practice and AHPRA/NMBA standards.
Pricing
• Supports are charged at current NDIS price limits for RN services.
• Private services are charged at agreed hourly rates.
• Travel is billed according to NDIS rules, including:
– Travel time (up to 30 minutes each way)
– 0.97c per km (non-remote)
– Reasonable provider expenses such as parking or tolls
• Report writing, documentation or letters may be billed separately when required.
Cancellations
• Less than 24 hours’ notice will incur a cancellation fee equal to the scheduled service.
• No-shows or missed telehealth calls may be billed in full.
Participant Rights
You have the right to:
• Safe, high-quality, culturally respectful care
• Privacy and confidentiality
• Be treated with dignity and respect
• Make choices about your supports and who delivers them
• Receive services free from abuse, neglect, violence or exploitation
Participant Responsibilities
You agree to:
• Provide accurate and up-to-date information
• Inform the provider of changes to your health, circumstances or NDIS plan
• Treat staff with courtesy and respect
• Ensure a safe environment for service delivery
• Pay invoices by their due date
Provider Responsibilities
Momentum Health Consulting agrees to:
• Deliver safe, competent and appropriate clinical services
• Respect your rights, privacy and independence
• Communicate any changes to scheduled appointments promptly
• Store all clinical records securely for a minimum of 7 years
• Declare any conflicts of interest
• Follow NDIS incident management requirements
Continuity of Supports
If Momentum Health Consulting is unable to provide supports, we will notify you and assist you to find alternate providers if required.
Feedback & Complaints
You may provide feedback or make a complaint at any time.
We will respond within 5 business days.
If you are not satisfied, you may contact:
NDIS Quality and Safeguards Commission
Phone: 1800 035 544
Email: complaints@ndiscommission.gov.au
Consent to Share Information
☐ I consent to Momentum Health Consulting communicating with my GP, allied health providers, support coordinator, plan manager or any relevant providers to support my care.
Consent may be withdrawn at any time in writing.
Ending this Agreement
Either party may end this agreement with 14 days’ written notice.
Final invoices will be issued for supports already delivered.
Emergency & After-Hours
Momentum Health Consulting does not provide emergency or crisis response services.
In an emergency, call 000 or attend your nearest hospital.
Representative Details (If applicable)
Representative Name: ______________________________________
Relationship: ______________________________________________
Phone/Email: ______________________________________________
Signature: _________________________________________________
Signatures
Participant / Representative Name:
Signature:
Date: ____ / ____ / ______
Provider (Momentum Health Consulting):
Signature:
Date: ____ / ____ / ______