My Plan Manager – Client Consent to Obtain & Release Information Form
CP-FM-SD: 03.01.11
Revision (Sept 2022)
Page
1
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Client Consent to Obtain & Release Information Form
Note: This form can only be completed by the Client or the Authorised Representative
________________________________________________________________________________
Privacy Policy:
I hereby acknowledge that My Plan Manager.com.au Pty Ltd ACN 617 963 676 (My Plan Manager)
has provided me with access to My Plan Manager’ Privacy Policy which sets out;
- my right to access personal information;
- my right to withdraw my consent at any time; and
- what personal information will be collected and disclosed and why.
Part 1: NDIS Participant Details
Full Name of Participant:
NDIS Number :
Part 2: Authorised Representative
PL E ASE NOTE:
Only complete this section if the Participant is not the primary decision-maker
Full Name of Authorised Representative :
Relationship of Authorised Representative with Participant
An immediate
p arent/guardian
A person appointed by
the NDIA as a Plan
N o minee
Th ird Party legally
appointed Guardian
Description of
Relationship (e.g.
mother)
____________________
Part 3: Service Providers
Please provide details of Service Providers with whom My Plan Manager can share information for
the purposes of providing plan management services under the Service Agreement with the
Participant/Authorised Representative.
No Service Providers
All Service Providers
Only the following Service Providers: -
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
My Plan Manager – Client Consent to Obtain or Release Information Form
CP-FM-SD: 03.01.11
Revision (August 2022)
Page
2
of
2
Part 4: Support Co-Ordinator or Recovery Coach (if applicable)
Please provide details of Support Co-Ordinator / Recovery Coach business with who My Plan
Manager can share information for the purposes of providing plan management services under the
Service Agreement with the Participant/Authorised Representative.
Business Name:
Contact Person:
(if applicable)
Support Co-Ordination or Recovery
Co ach:
Individual Contact Email:
Business Contact Email:
(for
circumstances in which permission is
provided to share information with the
business when the main contact is not
available or there is no main contact
person).
Telephone:
Support Co-ordination Recovery Coach
I consent to Support Co-Ordinator/Recovery Coach having “
READ ONLY
” access to my MPM on-line
account. Please Tick if you provide consent.
Part 5: Audit Purposes
I am aware that I am automatically enrolled in audit processes and may be contacted by the audit team of
My Plan Manager for interviews and/or have files reviewed to ensure that My Plan Manager complies with
the NDIS Practice Standards. I am aware that if I do not want to participate in this audit process, My Plan
Manager will document and respect that decision.
Please tick if you d o not wish to be a part of the audit process- Tick Box:
Part 6: Signature
I declare the information I have provided in this document is true and accurate to the best of my knowledge.
I have not deliberately provided any false or misleading information. I understand that I may revoke this
consent at any time, by sending written notification to My Plan Manager at
enquiries@myplanmanager.com.au.
P rint Full Name:
Signature:
Date:
Please note: SIGNATURE OF PERSON COMPLETING FORM
(MUST
be either t he NDIS P articipant or
an Authorised Representative who is recognised by the NDIA a s the plan nominee)
