Online Client Application: NDIS Clients Your DetailsName* First Last Address* Street Address Address Line 2 City State Postcode Mobile*Work PhoneEmail* Enter Email Confirm Email Date of Birth* Date Format: DD slash MM slash YYYY Referring Health Professional (eg Doctor) Details:Referring Health Professional Name:*Referring Health Professional Address* Street Address Address Line 2 City State Postcode Referring Health Professional Email Please attach your medical referral here (if applicable)Your NDIS DetailsIs your NDIS claim:* Self-managed: You will be required to pay at private rates at the time of your consultation Portal claim through the NDIA Third-party managed (please complete the third-party managed section) NDIS Number*Please attach a copy of your latest NDIS plan here:*Third-Party ManagedName of Third-Party ManagerAddress of Third-Party Manager Street Address Address Line 2 City State Postcode Contact Officer Name:Contact Officer Phone:Contact Officer Email: DeclarationI understand and acknowledge that:* The above information is true to the best of my knowledge I will at all times be responsible for payment of my account in full I will need to provide payment of my account in full at private rates at the time of consultation until I have provided all of the information and documents required CAPTCHA
