NDIS Service Agreement Form

1. Agreement Details

Date of Agreement

2. Participant Details

Participant Name

Phone Number

Email

Street Name

City / Suburb

State

Postal Code

3. NDIS Plan Details

NDIS Number

How is your NDIS Plan managed?

Self Managed

Plan Managed

NDIA Managed

If managed by Plan Manager

Plan Manager Business Name

Contact Person Name

Contact Person Email

Contact Person Mobile

Email Address to Send Invoices

Monthly Budget for Transport Funding

Upload a Copy of NDIS Plan (optional)

4. Provider Details

Provider: Northern Rivers Taxis Pty Ltd

Provider Address: 9/75 Conway Street, Lismore 2480

Provider Phone: 0266252113

ACN: 679920239

Email: admin@countrycabs.com.au

NDIS Registration ID: 4-K7BHOCK

5. Commencement and Duration

Commencement Date

Contract Type

6. Schedule of Supports

Service Type: Taxi Transport Services

Provision Method: Phone booking, online booking system.

Class of support:: 0108 assist travel/ transport.

Line Item: 02_052_0108_1_1 – Transport – Assisted.

Service Delivery Timeframe: As requested by the Participant.

Duration of Service: Ongoing / Specific time frame

Cost Structure: As per taxi fare chart + $2.50 booking fee (not for hail or rank pickup).

7. Responsibilities of Provider

Deliver transport services professionally and on time.
Communicate effectively and respectfully with the Participant.
Maintain confidentiality and provide invoices promptly.

8. Responsibilities of Participant

Provide accurate and timely transport details.
Respect the rights and dignity of drivers and staff.
Communicate any changes or feedback.
Ensure timely payment as per agreement.

9. Signatures

Participant Signature

Date

— OR —

Provider Representative Signature

Date

10. Confirmation of Agreement

By submitting this form, you agree that:

Country Cabs (Northern Rivers Taxis Pty Ltd) will provide transport under your NDIS plan as per the NDIS Price Guide.
Invoices are issued monthly and payable within 14 days of the invoice date.
You will notify Country Cabs if your plan or funding changes.
Cancellations should be made at least 24 hours in advance.
Personal information is kept confidential according to privacy laws.

NDIS SERVICE AGREEMENT

If managed by Plan Manager