Form 1 Service Agreement For Support Coordination & Support Services

Thank you for considering Heart to Heartbeat to be your support service and/or support coordinator under the National Disability Insurance Scheme (NDIS).

Please make sure you have read the terms within our Service Agreement before proceeding.

When you are ready to begin, start to complete the online form below. You can save as you go and return to complete at a later date.

Please note – only plan nominees or parent/ guardians can enter information and submit this form.

Registration Form 2.0

HEART TO HEARTBEAT (H2HB)

SERVICE AGREEMENT

Business Details

Business Name: Heart to Heartbeat Pty Ltd

ABN: 48 651 353 829

Phone: 0455 257 797

Email: admin@hearttoheartbeat.com.au

Accounts Email: hearttoheartbeat@gmail.com

Website: www.hearttoheartbeat.com.au

Postal Address: PO Box 773, Caboolture QLD 4510

Service Area: Moreton Bay Region and surrounding areas

Important: Please read this Service Agreement carefully. If you do not understand any part of this agreement, please contact Heart to Heartbeat before signing. We are happy to explain any section.

What is a Service Agreement?

This Service Agreement is a legal agreement between you, the Participant, and Heart to Heartbeat (H2HB).

1. Purpose of this Agreement

This agreement outlines the supports Heart to Heartbeat (H2HB) will provide and the responsibilities of both the Participant and H2HB.

This agreement has been developed in accordance with the NDIS Act 2013, NDIS Practice Standards and NDIS Code of Conduct.

2. Duration of Agreement

This agreement starts on the date it is signed and continues until:

The participant's NDIS plan ends and is reviewed.
A new agreement replaces this agreement.
Either party ends the agreement in accordance with Section 10.

This agreement will be reviewed at least annually or when significant changes occur.

3. Supports to be Provided

H2HB may provide supports including:

In-home supports
Community access
Social and recreational activities
Skill building and independence supports
Transport supports
Group activities
Support Coordination, where applicable

Supports may be provided on a:

1:1 basis
Shared support basis, such as 1:2

where appropriate and agreed to by the participant.

4. H2HB Responsibilities

H2HB will:

Deliver supports safely and professionally.
Treat participants with dignity and respect.
Promote choice, control and independence.
Protect privacy and confidentiality.
Maintain appropriate records.
Communicate any changes affecting supports.
Follow all NDIS Practice Standards and legislation.

5. Participant Responsibilities

Participants agree to:

Treat staff respectfully.
Provide information relevant to supports.
Notify H2HB of changes to circumstances.
Participate in planning and reviews where possible.
Inform H2HB if their NDIS plan changes.
Follow agreed cancellation requirements.

6. Fees and Charges

Supports will be charged in accordance with the current NDIS Pricing Arrangements and Price Limits.

Additional participant costs such as:

Meals
Activity entry fees
Tickets
Personal purchases

are the responsibility of the participant unless otherwise agreed.

Transport may be charged in accordance with NDIS guidelines and H2HB policies.

7. Changes, Cancellations and Missed Supports

Regular Supports

H2HB requests a minimum of 24 hours' notice for cancellation of regular supports.

Where less than 24 hours' notice is provided, the arranged support shift will be charged in full.

Group Activities and Special Events

Group activities, community programs, social events and special activities often require advance staffing, transport and booking arrangements.

A minimum of seven (7) days notice is requested for cancellations from these activities.

Where cancellation occurs within seven (7) days, H2HB may charge for support costs and any reasonable unrecoverable expenses already committed on behalf of the participant.

Missed Supports

Eight (8) repeated missed supports without reasonable notice may result in a review of ongoing service delivery and prompt a Service Agreement cancellation.

8. Privacy and Confidentiality

H2HB respects your privacy.

Personal information will only be collected, stored and shared where necessary to provide supports, meet legal obligations or comply with NDIS requirements.

Information is managed in accordance with H2HB Privacy Policy and relevant privacy legislation.

9. Feedback and Complaints

Participants have the right to provide feedback, make complaints or raise concerns without fear of disadvantage.

Complaints can be made to:

Heart to Heartbeat (H2HB)
Phone: 0455 257 797
Email: admin@hearttoheartbeat.com.au

If a complaint cannot be resolved internally, participants may contact the NDIS Quality and Safeguards Commission.

10. Ending this Agreement

Either party may end this agreement by providing two (2) weeks written notice.

H2HB may immediately suspend or end supports where:

Safety is at risk.
Services can no longer be safely provided.
There is a serious breach of this agreement.
Funding is no longer available.

Where possible, H2HB will assist with a safe transition to alternative supports.

11. Participant Rights

Participants have the right to:

Be treated with dignity and respect.
Make choices about their supports.
Be involved in decisions affecting them.
Access information about their services.
Make complaints without fear of retaliation.
Receive services that are safe and person-centred.

If You Cannot Sign Yourself

If you are unable to sign, a trusted person can sign on your behalf with your consent. This person is your Representative and may be:

A parent or family member
A partner or trusted support person
A legally appointed guardian or power of attorney under Queensland law

If You Do Not Want to Go Ahead with This Agreement, You Are Not Required to Sign

You are never obligated to sign this agreement.

You are free to choose another NDIS provider at any time.

Other Providers & Payment Arrangements

This agreement only covers services provided by Heart to Heartbeat.

It does not cover payment arrangements between you and other providers. We may help coordinate supports, but each provider has their own agreement.

Schedule of Supports

Heart to Heartbeat will provide supports according to:

Your NDIS plan
The NDIS Price Guide/current pricing arrangements
Your agreed supports and goals
NDIA portal information, where applicable
Plan Manager information, where applicable
Self-managed arrangements, where applicable

Support Coordination Services

This agreement also covers Support Coordination services under NDIS rules and Queensland legislation, where Support Coordination is provided by H2HB.

Support Coordination Level 2 Includes:

Coordinating multiple services
Connecting you with providers
Helping negotiate service agreements
Monitoring support effectiveness
Assisting with plan reviews
Supporting budget use and service adjustments

Participant Responsibilities — Support Coordination

You agree to:

Provide accurate information
Share plan changes
Attend scheduled meetings
Communicate cancellations
Treat staff respectfully

Goods and Services Tax (GST)

For GST purposes, both parties confirm that the supports provided under this Service Agreement are intended to be reasonable and necessary supports as outlined in the Participant's NDIS Plan under the National Disability Insurance Scheme Act 2013 (Cth).

Legal Compliance

This agreement is designed to comply with:

NDIS Act 2013
NDIS Practice Standards
NDIS Code of Conduct
Disability Services Act 2006 (Qld)
Information Privacy Act 2009 (Qld)
Other relevant Commonwealth and Queensland legislation

Acknowledgement: By submitting this form, I acknowledge that I have read and understood this Service Agreement and agree to the terms outlined above.

Heart to Heartbeat Pty Ltd

Authorised Representative

Stu Suniula
Director

Signed by Director of Heart to Heartbeat – Stu Suniula

Please complete the Service Agreement Form to the best of your ability.

Please note that your Support Coordinator cannot sign this form for you.

Participants' Full Name(Required)

First Last

Name of person who has NDIS PLAN

Contact Number

Welcome, is this your first time completeting a Service Agreement with Heart to Heartbeat?(Required)

Yes - This is a new service agreement with Heart to Heartbeat

No - I am renewing my Service Agreement with Heart to Heartbeat and just need to update details

Mandatory Acknowledgement(Required)

If 'No - I am renewing my Service Agreement with Heart to Heartbeat and just need to update details' is selected:

I acknowledge that this Service Agreement reflects my current NDIS plan dates and H2HB’s current NDIS-aligned pricing.

Please select which categories you would like to update:

Personal Information

NDIS Information

Travel and Transport

Fund Management

Coordinator of Supports

Participant's Information

Full Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Age (at time of application)

Gender

Male

Female

Other

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Participant Headshot Upload

Max. file size: 256 MB.

A clear headshot of new participants is helpful in the event of an emergency and also assists our support workers to identifiy you upon meeting. We do not post or use these photos publicly.

Do you have a Companion card?(Required)

Yes

Companion Card Copy Upload

Accepted file types: jpg, png, pdf, jpeg, , Max. file size: 256 MB.

Emergency Contact

Full Name(Required)

First Last

Emergency Contact Phone Number(Required)

Relationship to Participant(Required)

Email(Required)

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

NDIS Information

NDIS Number(Required)

National Disability Insurance Scheme (NDIS)

Please choose which support service you require?

Support coordination

Support services

Both

Plan From Date(Required)

Plan To Date(Required)

All rates displayed reflect NDIS hourly rates and are subject to change without notice. * Current pricing arrangements can be found on the NDIS website *

Support services

Please tick all codes that can be charged. Here is a list of Support and COS codes.

Detailed description of services required by Heart to Heartbeat(Required)

Example 1: I require 1:1 support for 4 hours per week. Example 2: I require casual bookings into a holiday program.

Total funding to be allocated for the agreement period(Required)

Travel and Transport

Support worker time for transport is charged from the time the worker arrives to begin supports until the support ends. For example, if the participant attends a four-hour activity and travel takes 30 minutes each way, up to five hours of support may be charged from the participant’s NDIS plan at the applicable support rate. Transport kilometres are charged at $1.00 per kilometre and may be claimed from the participant’s Transport Budget or Core Supports, where permitted. For group activities, support worker time is charged at the applicable group support rate. Transport kilometres will be divided between the participants travelling in the vehicle.

Do you have an allowance in your NDIS (National Disability Insurance Scheme) Plan for transport?

Yes

If yes, is this paid directly to you or does the NDIS (National Disability Insurance Scheme) manage this item?

Directly

NDIA

Support Coordinator

Please enter your Support Coordinators Information, if you have one.

Support Coordinators Name

Support Coordinators Email

Support Coordinators Phone Number

Support Coordinators Company Name

If they are part of one

Fund Management

Tick which statement best suits your individual circumstances

Fund Management Arrangement(Required)

Funding is Self-Managed

Funding Managed by a Plan Management Provider

The Participant is self-managed and will provide payment under this Service Agreement. After providing these supports, H2HB Pty Ltd will claim payment for those supports from the participant.

The Participant has nominated the Plan Management Provider (listed below) to manage the funding for supports provided under this Service Agreement. After providing these supports, Heart to Heartbeat will claim for those supports from:

Plan Management Provider’s Name

Main Plan Management Contact

First Last

Plan Manager's Email

Plan Manager's Phone

NB: For any supports Heart to Heartbeat are invoicing you for (e.g., transport or for self-managed supports), we will require payment within 7 days by electronic transfer. All other invoices for supports either to the NDIA or Plan Manager will be invoiced weekly and require payment within 7 days.

Accepting this Agreement

This Service Agreement will be effective from the date entered below and continue through until any NDIS plan changes are made and/or cancelled by either party.

Participant / representative completing this form

First Last

Relation to participant

Was the participant involved in the form completion?

Yes

If no, please specify why

Service Agreement Start Date(Required)

Either todays date or date of first support shift.

Service Agreement End Date/ NDIS Plan End Date(Required)

Plan Managers require an end date to an agreement. This date is the same as your 'Plan to date'. When your plan rolls over to it's new dates you are required to update your Service Agreement with the new dates provided in your new NDIS Plan.

I authorise Heart to Heartbeat to initiate and accept my Service Bookings on the NDIS (National Disability Insurane Scheme) portal or by the NDIS Plan Manager I have nominated on this agreement.(Required)

Yes

Signature of Participant / Participant’s Representative

Have you got any questions or is there any other information you would like us to be made aware of?