CONTINENCE GEELONG NDIS REFERRAL FORM

Name

Address

Date of Birth

NDIS Plan Start Date

NDIS Plan End Date

Participant’s Phone

Participant’s email

NDIS Number

Appointment Contact Name

Relationship to Participant

Appointment Contact Phone

Appointment Contact Email

N.O.K- if necessary

Medical History/Disability

Occupational Therapist Details

Reason for referral

Any issues or alerts in the home?

The participant is aware of this referral and consents to a continence assessment.

Managed Type (If plan managed, please document an email address:)

Self Managed Plan Managed Agency Managed

Plan managed email

Referrer Name

Referrer Phone

Referrer Email

SERVICE AGREEMENT

I acknowledge that I have read and understand all relevant terms and conditions. The signing authority acknowledges responsibility for ensuring payment of service invoice/s.

The Continence Nurse Consultant will provide the continence assessment for me in my home or via Telehealth (video or phone). The Continence Nurse Consultant will provide an appropriate outcome report +/- assistive technology quotation to me.

I have the right to request access to my information held on file by the Continence Nurse Consultant for the purposes of correction, clarification and addition of further details relevant to assessment. It is my responsibility or my authorised nominee, to provide the Continence Nurse Consultant with any revocation of this consent as soon as possible, where applicable, in writing. Rights & Responsibilities of the Continence Nurse Consultant: The Continence Nurse Consultant may collect, use, disclose, store and handle personal information about me for the primary purpose of providing services to me, managing the supply of these services, and, where necessary sharing it with other health service providers and health professionals, who may be able to further assist me, in accordance with the Information Privacy Act 2000 (IP Act) and the Health Records Act 2001 (HR Act)

Cancellation Policy:
Failure to attend a scheduled appointment or cancellation with less than one (1) CLEAR BUSINESS DAY notice may incur a fee 50% of the expected scheduled NDIS fee as per current NDIS Guidelines. All feedback, compliments or complaints are encouraged by emailing contactus@continencegeelong.com.au

A Continence Assessment takes 4-6 hours for the consultation, report (with pricing of products), strategies and follow-up with other care providers. Typically a non-complex continence report takes 4 hours. Continence Assessment is a minimum of $676.64 (no GST) and a maximum of $1,014.96. If applicable, travel costs @ $2.732 per minute. Capped at a maximum 30 minutes to the participant and 30 minutes from the participant back to work. 60 Minutes = $169.16.

Erica Pearce- Continence Geelong. ABN 25617608769
NDIA Service Provider No. 4-4331-1677
Mobile: 0447 312 048

Do you Accept the Service Agreement?

Yes No If the participant is not signing, have you discussed the above with the participant and is this Service Agreement accepted?

Acceptance of Continence Service Agreement Signature

Service Agreement signed by:

Date Signed