Fillable Access Request Form Complete this form to request (Department of Social Security and Welfare)

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Access Request Form Complete this form to request (Department of Social Security and Welfare)

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The Access Request Form Complete this form to request (Department of Social Security and Welfare) form is 9 pages long and contains:

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Country of origin: AUSTRALIA
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Released by the NDIA on
____/_____/_______
By ___________________
NDIA Office: ____________
Access Request Form
Complete this form to request to become a participant in the National Disability Insurance Scheme
(NDIS). You must provide proof of age, residence (including citizenship or visa status) and disability (or
your need for early intervention supports) with this Access Request Form. We cannot make a decision
on your access request without this information.
If you have questions about this form, need help to complete it or would like more information about the
NDIS, please contact us:
Phone: 1800 800 110
TTY: 1800 555 677
Speak and Listen: 1800 555 727
Internet Relay: Visit http://relayservice.gov.au
and ask for 1800 800 110
Email: NAT@ndis.gov.au
Please return the completed form to:
Mail: GPO Box 700, Canberra, ACT 2601
Email: NAT@ndis.gov.au
or
In person: take it to your local NDIA office
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 1 of 9
ARF: V 8.1 – 8 April 2020
Part A: Your details (the person wishing to become an NDIS participant)
Full name
Date of birth (DD/MM/YYYY)
Gender
☐ Male
☐ Female
☐ Unspecified
Are you of Aboriginal or Torres Strait
Islander origin?
☐ No
☐ Yes – Aboriginal
☐ Yes – Torres Strait Islander
☐ Yes – Aboriginal and Torres Strait Islander
☐
Do not wish to disclose
Country of birth
Language spoken at home
Are you living in Australia
permanently?
☐ Yes
☐No
Current home address
(include state and postcode)
Postal address
(include state and postcode)
☐ As above
If different to current home address:
For Western Australia or Northern
Territory only: What was your home
address on 1 July 2014?
☐ Same as current home address above
If different to current home address:
Are you an Australian Citizen?
☐ Yes
☐ No
If NO, what type of visa do you
have?
☐ Permanent visa
☐ Protected special category visa
☐ Other including temporary visa (please specify below)
Visa Type:
Nationality:
Passport Number:
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 2 of 9
ARF: V 8.1 – 8 April 2020
Part B: Your privacy and consent to collect and share your information
The National Disability Insurance Agency (NDIA) collects personal information to help us determine
whether you can access the NDIS. As a participant, the NDIA will also collect and use your information
to help develop and implement your NDIS Plan and do other things related to the NDIS.
In addition to collecting certain information from you, we may contact your service providers, health and
medical practitioners and other government agencies to request the provision of personal and health
information about you which will help us to determine whether you meet the access requirements for the
NDIS and, if so, to provide supports to you under the NDIS.
If you live in Shared Supported Accommodation, (e.g. a home shared with other people with disabilities
that includes shared support from paid staff), we may also disclose your personal information to
personnel employed within the group home to enable the Agency to collect further personal information
about you in order to support the development of your NDIS plan if you become a participant.
Please note that if you do not consent to the collection of your personal information, the NDIA may not
be in a position to determine whether you meet the access requirements for the NDIS or develop your
NDIS Plan if you become a participant. More information about the collection, use, disclosure and
storage of your personal information by the NDIA can be accessed on our online Privacy Notice and
Privacy Policy at www.ndis.gov.au/privacy
or by contacting the NDIA.
Do you consent to the NDIA collecting your
information including from these third parties,
for the purposes of determining whether you
meet the access requirements for the NDIS
and to help develop or implement your NDIS
Plan if you become a participant?
☐ Yes, I consent
OR
☐ No, I do not consent.
You can give us consent to obtain information about your age, disability, and residence from
Centrelink (below) or you can provide us with certified copies of the required documents yourself.
We cannot make a decision without this information.
The Australian Government
Department of Human Services
(including Centrelink and Medicare)
☐ Yes, I consent
My CRN is:
OR
☐ No, I do not consent.
I will provide the information myself.
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 3 of 9
ARF: V 8.1 – 8 April 2020
Part C: How would you like the NDIA to contact you?
How would you like us to contact
you?
☐ Home phone (insert number):
TTY (if applicable):
☐ Mobile phone (insert number):
☐ Email (insert address):
How would you like to receive
letters?
☐ Email
☐ Post
Do you need an interpreter to help
us talk with you?
☐ No
☐ Yes
If yes, specify language:
☐ Do not contact me directly.
Instead, contact:
☐ My parent/legal guardian or representative (Part D)
☐ Other (please specify):
Part D: Parent, legal guardian or representative details (if applicable)
Complete this section if you are filling out this form for:
• a person aged under 18 for whom you have parental responsibility, OR
• a person for whom you are a representative or a legal guardian.
You do not need to complete this section if you are just helping the person fill out this form.
NOTE: If you are a legally appointed guardian, you will need to provide your Proof of Identity (POI) and
guardianship status to the NDIA. This information can be verified through the Australian Department of
Human Services (Centrelink) using the CRN provided on page 2 (if applicable) or you can provide copies
of two POI documents (or a ‘Government issued photo card’) and the guardianship document with this
form.
Full name
Relationship to person making request
Phone (include TTY if applicable)
How would you like to receive letters?
☐ Email
Email address:
☐ Post
☐ Same address as person making request
If different address, please provide details:
Do you need an interpreter?
☐ No
☐ Yes
If yes, specify language:
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 4 of 9
ARF: V 8.1 – 8 April 2020
Part E: Information about your carers and family members (if applicable)
Carer’s full name
Contact phone number
(include TTY if applicable)
Will your carer be taking part in
the planning conversation?
☐ Yes
☐ No
Do you have another family
member who is, or is seeking to
become, an NDIS participant?
☐ Yes
☐ No
If yes, please provide their name:
Part F: Your disability, or need for early intervention supports
So we can determine whether you (or your child) meet the disability or early intervention access
requirements (including developmental delay), you need to provide us with information about your
disability or impairment.
Primary disability:
(This is the disability that has the
most impact on your daily life)
Please list other disabilities
(if any):
Did you acquire your disability
because of an injury?
☐ Yes
☐ No
Are you seeking, or have you
previously sought compensation
related to your disability or
injury?
☐ Yes
☐ No
If you have undertaken one or more of the following assessments or reports in relation to your
disability, please provide a copy with your Access Request Form.
• The Care and Needs Scale (CANS)
• Vineland Adaptive Behaviour Scales, 2nd Ed (Vineland-II)
• Diagnostic and Statistical Manual of Mental Disorders, 5th Ed (DSM-5) – Autism Spectrum Disorder
• Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM-4) – Autism Spectrum Disorder
• Childhood Autism Rating Scale (CARS)
• Adaptive Behaviour Assessment System (ABAS)
• Autism Diagnostic Observation Schedule (ADOS)
• Gross Motor Functional Classification Scale (GMFCS)
• Communication Function Classification Score (CFCS)
• Manual Ability Classification System (MACS)
• Diagnostic and Statistical Manual of Mental Disorders, 5th Ed (DSM-5) – Intellectual Disability
• Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM-4) – Intellectual Disability
• Clinical Evaluation of Language Fundamentals, 4th Ed
• Wechsler Preschool and Primary Scale of Intelligence, 3rd Ed (WPPSI-III)
• Wechsler Intelligence Scale for Children (WISC-IV)
• IQ test
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 5 of 9
ARF: V 8.1 – 8 April 2020
• Hearing Loss (Measured in decibels in better ear)
• D
isease Ste
ps
• E
xpanded Disability Status Scal
e
• Lev
el of lesio
n
• ASI
A Scor
e
• Mod
ified Rankin Scal
e
• V
isual acuity lev
el
• V
isual field loss (horizontal and vertical
)
• W
orld Health Organisation Disability Assessment Schedule (WHODAS 2.
0)
• Other
We need supporting information about your disability and the impact it has on your mobility,
communication, social interaction, learning, self-care and/or ability to self-manage.
You can do this by:
☐
Providing us with copies of reports, letters or assessments from your health or education
pr
ofessional detailing your (or your child’s) impairment and the impact it is has on daily life
OR
☐ By asking a professional to complete the section below:
Full name of professional (health or
education)
Professional qualification
Phone
Email
Length of time you have known or treated
the person making request?
Primary disability and any secondary
disabilities:
Current treatment (if any):
Is there any other treatment that is likely to
remedy the impairment?
☐ Yes
☐ No
1.
M
obility/motor skill
s
M
oving around the home (crawling/walking), getting in or out of bed or a chair, leaving the home and
moving about in the community
Note: Assistance required does not include commonly used items such as glasses, walking sticks, non-
slip bath mats, bathroom grab rails and hand rails installed at stairs
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 6 of 9
ARF: V 8.1 – 8 April 2020
Does the person require assistance to
be mobile because of their disability?
☐ No, does not need assistanc
e
☐ Yes, needs special equipment
☐ Ye
s, needs assistive technol
ogy
☐ Ye
s, needs assistance from other persons
:
(
physical assistance, guidance, supervision or prompti
ng)
I
f yes, please describe the type of
assistance required:
2. Communication
B
eing understood in spoken, written or sign language, understanding others and express needs and
wants by gesture, speech or context appropriate for age
Does the person require assistance to
communicate effectively because of
their disability?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐ Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)
I
f yes, please describe the type of
assistance required:
3. S
ocial Interacti
on
M
aking and keeping friends, interacting with the community (or playing with other children), coping with
feelings and emotions
Does the person require assistance to
interact socially because of their
disability?
☐ No, does not need assistanc
e
☐ Ye
s, needs special equipm
ent
☐ Yes, needs assistive technology
☐ Ye
s, needs assistance from other persons
:
(physical assistance, guidance, supervision or prompting)
I
f yes, please describe the type of
social interaction assistance required:
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 7 of 9
ARF: V 8.1 – 8 April 2020
4. Learning
Understanding and remembering information, learning new things, practising and using new skills
Does the person require assistance to
learn effectively because of their
disability?
☐ No, does not need assistance
☐
Yes,
needs special equipment
☐
Yes,
needs assistive technology
☐
Yes,
needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)
If yes, please describe the type of
assistance required:
5. Self-Care
Showering/ bathing, dressing, eating toileting, caring for own health (not applicable for children under
two years of age)
Note: Assistance required does not include commonly used items such as non-slip bath mats, bathroom
grab rails and hand rails installed at stairs
Does the person require assistance with
self-care because of their disability?
☐ No, does not need assistance
☐
Yes,
needs equipment/ assistive technology
☐
Yes,
needs assistance from another person in the areas
of:
☐
show
ering/bathing
☐
eati
ng/drinking
☐ overnight care (e.g. turning)
☐
to
ileting
☐
dre
ssing
If yes, please describe the type of
assistance required:
6. Self-Management
Doing daily jobs, making decisions and handling problems and money (not applicable for children under
8 years of age)
Does the person require assistance with
self-management because of their
disability?
☐ No, does not need assistance
☐
Yes,
needs special equipment
☐
Yes,
needs assistive technology
☐
Yes,
needs assistance from other persons:
(physical assistance, guidance, supervision or prompting
If yes, please describe the type of
assistance required:
Signature of Professional
Date
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 8 of 9
ARF: V 8.1 – 8 April 2020
Part G: Change of circumstances
The law requires you to tell the NDIA if a change of circumstances happens (or is likely to happen) that
might affect your request to be a participant in the NDIS or, if you become a participant, that might affect
your status as a participant or your NDIS Plan.
For example, you must tell us if your disability support needs change, you move house or overseas, or
receive compensation relating to an injury.
You must tell us as soon as you reasonably can. You can do this in person, over the telephone or
by letter, email or fax.
Part H: Signature
When I sign this Access Request Form:
• I certify that the information I have provided is true and correct and that I have given all of the
information and documents that I have or can get that are required by this Access Request Form.
• I understand that giving false or misleading information is a serious offence.
• I understand that I am giving consent for the NDIA to do the things with my information set out in
Part B and with the people I have indicated in Part D. I understand that I can withdraw my
consent for the NDIA to do things with my information at any time by letting the NDIA know.
• I understand that I can access the NDIA’s Privacy Notice and Privacy Policy on the NDIA website
or by contacting the NDIA.
• I understand that if I have selected email under Part C as my preferred means of communication,
that the NDIA may email me sensitive or confidential information. I understand that the NDIA
cannot guarantee the security of the email once it leaves the NDIA system.
• I understand that my access to the following Commonwealth programs will cease (if applicable) if
I become a participant in the NDIS:
- Helping Children with Autism and Better Start
- Mobility Allowance
Signature:
Date:
Full Name (please print):
If you have signed this Access Request Form on behalf of the person wishing to become an NDIS
participant, please complete the details below. It is an offence to provide false or misleading
information.
Full name of person completing this form (please print):
Relationship to person wishing to become an NDIS participant:
We may require you to provide evidence of your authority to sign on behalf of the person.
Personal–In-Confidence when complete OFFICIAL DOCUMENT—DO NOT COPY Page 9 of 9
ARF: V 8.1 – 8 April 2020
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Completed 20 November 2020

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