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Consent to share information
and share my plan
It may be necessary for Marli and Moe (MM Disability PTY LTD - 405008675) to contact a third party
to seek information about you. However, Marli and Moe needs your permission to do so.
This form also gives the National Disability Insurance Agency (NDIA) permission to share your
information on your behalf.
The information that can be shared will depend on the permission you give us on this form.
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 Marli and Moe in providing you Support Coordination
If you agree to Marli and Moe sharing and receiving information about you from third parties, please
fill in and sign the form on the next page.
Marli and Moe will share this form with third parties to show them you have agreed for Marli and
Moe 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 Marli and Moe to have permission anymore, you can withdraw your consent by contacting us.
However, if Marli and Moe 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 Marli and Moe to ask a third party about you, we will ask you for your
information instead.
There are certain circumstances where Marli and Moe 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.
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Information about you:
Surname:
Given name(s):
Date of birth:
NDIS number:
Address:
Phone number:
Email:
Is there another person who we should communicate
with when supporting you to support you to make
decisions?
No
Yes (if yes, complete below)
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.
Please mark the relevant box below to indicate your relationship to the participant
☐ Child representative
☐ Plan nominee
☐ Legally appointed decision maker
Surname:
Given name(s):
Relationship to participant:
Address:
Phone number:
Email:
What is your or your representatives preferred method of contact?
Email
Phone
Mail
Do you or your representative need an interpreter to support us to communicate with you?
No
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Giving consent
Do you consent to Marli and Moe talking to other people about you; giving them information
about you and getting information about you from:
The National Disability Insurance Agency (NDIA)?
Yes, I consent
No, I do not
consent
Your medical practitioners and health
professionals?
Yes, I consent
No, I do not
consent
Your School?
Yes, I consent
No, I do not
consent
N/A
Your workplace?
Yes, I consent
No, I do not
consent
N/A
State and Territory government departments?
Yes, I consent
No, I do not
consent
Members of my Family and or Friends?
Yes, I consent
No, I do not
consent
Service providers?
Yes, I consent
No, I do not
consent
Is there anyone or any providers that we must not speak to or share information with, except when
required to by law?
Name of person and/or organization:
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 the following organisation.
Organisation
Marli and Moe Support Coordination - MM Disability PTY LTD - 405008675
Please mark the relevant boxes below to indicate the information you give the NDIA consent to share with Marli
and Moe
My personal information
☐ My name, date of birth, NDIS participant number and NDIS participant status
☐ My address, email and phone number
☐ Details about my Carers
☐ Details about my Informal supports
☐ Details about my Service providers
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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 below to indicate the purpose of your consent for us to share this information
☐ My NDIS Access request
☐ To review my NDIS plan
☐ To implement my NDIS plan
☐ To review a decision made by the NDIA
☐ 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 box below to indicate the length of time you are providing the consent for
☐ Ongoing
☐ For the duration of my current NDIS plan
Signature
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 Marli and Moe handles my personal
information by requesting their Privacy Policy.
I understand I have given Marli and Moe 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.
Name:
Date:
Signature: