beyonddisabilitysupport
MaleFemaleOther
Interpreter Required YesNo
Preferred option for communication EmailFacetimePhone Call
Do you identify as Aboriginal and/or Torres Strait Islander? * YesNo
Is there a Guardianship and/or Administration order in place? YesNo
Would you like an advocate? —Please choose an option—YesNo
Please enter the details of the person you’d like to give authority to act on your behalf.
Full Name
Address
Relationship to you
Email address
Home Phone
Mobile Phone
Work Phone
Authority Effective From
By completing and signing this form, I agree to the following:
I authorise the provider to act on the instructions of my nominated person
I understand that provider is not responsible for any actions of my nominated person using this authority
I understand that this authority comes into effect from the date above or from when form is received whichever is the later.
I understand that I am giving my nominated person authority to access my information by telephone, email and letter
I understand I can write to or call the provider at any time to cancel this authority, and the provider will only cancel this authority if I ask them to in this way. Cancellation will not be effective until received by the provider
Disability / Medical Condition 1
Disability / Medical Condition 2
Disability / Medical Condition 3
Disability / Medical Condition 4
Disability / Medical Condition 5
Name
Phone Number
Email
Frequency of Use
Medicare Number
Expiry
Reference #
Private Healthcare Provider
Membership
Doctor
Phone
Funding —Please choose an option—NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)Self-ManagedPlan Managed
NDIS Plan
NDIS Number
NDIS End Date
Comments
Preferred name
Support workers preference (if applicable) MaleFemaleDo not mind
Religious Requirements
Cultural Requirements
Communication Device
Physical Assistance
Other Considerations
I understand that:
These records are owned by this organisation.
Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
I can ask to see records and receive a copy
Records are archived for a set period according to policy and procedure
I understand that all information obtained will be kept confidential.
To the best of my knowledge, the information provided in this form is true and correct:
Signature of Participant or Parent/Caregiver
Date
Relationship to participant
