Consent Form | Marley Ability

This information may include:

• Where you live, and information about you, such as your date of birth • • information about your disability • • your NDIS plan or funded supports • • medical and therapist reports • • other information that will assist Marley Ability in providing you Support Coordination •

If you agree to Marley sharing and receiving information about you from third parties, please fill in and sign the form on the next page.

Marley Ability will share this form with third parties to show them you have agreed for Marley Ability to talk to them about you and exchange information about you, if requested. If you do not want this to happen, you do not have to give your permission. If you decide you do not want Marley Ability to have permission anymore, you can withdraw your consent by contacting us. However, if Marley Ability does not have all the information it needs, the following things may happen: • Support Coordination Support may be ineffective and may take longer to coordinate and engage you with services • • You will need to be the intermediary contact between services and us as the support coordination to pass on the required information to either party, this may result in depletion of funds. • • If you do not permit Marley Ability to ask a third party about you, we will ask you for your information instead. • • There are certain circumstances where Marley Ability may also be required or allowed by law to talk to other people about you; give them your information or ask for information about you without your consent. •

Your Name *

First

Last

Date Of Birth *

Your NDIS Number *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

How would you like us to contact you? *

Is there another person who we should communicate with when supporting you to support you to make decisions? Please Tick Below

No
Child Representative
Plan Nominee
Legally Appointed Decision Maker

If Applicable, What is your representatives preferred method of contact?

If Yes, please fill out the details below.

Do you or your representative need an interpreter to support us to communicate with you?

If yes, please state which Language above.

Parent, legal guardian or representative

Fill out this section if you are completing this form on behalf of: • a person under 18 years for whom you have parental responsibility, or • a person for whom you are a legal guardian or representative. We may ask you to provide confirmation that you are authorised to represent the participant and to verify your identity.

Name of Parent, legal guardian or representative

Relationship to Participant

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email

Do you consent to Marley Ability talking to other people about you; giving them information about you and getting information about you from the NDIS? *

Please tick the box to agree.

Do you consent to Marley Ability talking to other people about you; giving them information about you and getting information about you from your medical practitioners and health professionals? *

Please tick the box to agree.

(You would edit this to fit your needs). Outline study duration, the purpose of the study, the study procedure, and highlight the fact the individual is voluntary participant. "I know that my participation is voluntary and that I can choose to withdraw from the research at any point."

Do you consent to Marley Ability talking to other people about you; giving them information about you and getting information about you from Providers that Provide Supports for Your NDIS Plan? *

Please tick the box to agree.

Do you consent to Marley Ability talking to other people about you; giving them information about you and getting information about you from your Family Members / Friends You have listed below?

Please tick the box to agree.

Please write below the included people you want to share your information with.

Family Member / Friend / Provider Names

Please leave this blank if there's no one you would like to include. This can be changed / modified or updated at any time.

Third party details & consent for NDIA Communication

I consent to the NDIA giving information about me (or the participant I am representing who is identified in this form), to Marley Ability (ABN: 85 107 236 231)

I consent to the NDIA giving information about me (or the participant I am representing who is identified in this form), to Marley Ability (ABN: 85 107 236 231) *

My name, date of birth, NDIS participant number and NDIS participant status
My address, email and phone number
Details about my Workers
Details about my Informal supports
Details about my Service providers

Please mark the relevant boxes above to indicate the information you give the NDIA consent to share with Marley Ability.

My NDIS Information *

The assessments and reports held about me by the NDIA
My NDIA Access Request Form
A copy of all parts of my current NDIS Plan
A copy of my current NDIS Plan’s Goals and Aspirations
A copy of my current NDIS Plan’s funding and support
My NDIS Contact

Please mark the relevant boxes above to indicate the information you give the NDIA consent to share with Marley Ability.

Purpose of Consent *

My NDIS Access request
To review my NDIS plan (DEFAULT FOR SUPPORT COORDINATION)
To implement my NDIS plan
To discuss an enquiry, complaint or feedback
To discuss a provider payment query
To discuss a provider quote
To discuss an Administrative Appeals Tribunal request
To discuss compensation I am or will be receiving

Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information. If you are unsure, you can leave it as the default, for Support Coordination purposes/review.

Please mark the relevant box below to indicate the length of time you are providing the consent for *

Ongoing
For The duration Of My NDIS Plan

By signing this consent form

I understand I can obtain further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. You can find this information on the NDIS website (ndis.gov.au/privacy)
I understand I have given the NDIA consent to give information about me to the third party or parties I have listed on this form so they can take the identified action/s on my behalf.
I understand I can obtain further information about how Marley Ability handles my personal information by requesting their Privacy Policy.
I understand I have given Marley Ability consent to ask for information about me and share my information with third parties.
I understand I can withdraw or amend my consent at any time.

Please Click All Of the Above, to show that you understand and agree to all of these consent items. If you have any questions, please contact us and we will help you as soon as possible.

Name of Person Signing this Form *

First

Last

Or Participant Name if Verbal Consent

Signature of Person Signing this consent form *

Verbal Consent Given?

Yes

Date *