NDIS Consent Share Template

Consent for your NDIS information

Please use this form to give your permission (consent) for the National Disability Insurance Agency (NDIA) to share your National Disability Insurance Scheme (NDIS) information with a person or an organisation who you choose. For example you might want to share some or all of your NDIS information with a family member who helps you to make decisions or with a provider you use regularly.

You don’t have to use this form to give your consent. You can let us know over the phone by calling 1800 800 110 or by contacting us in any of the ways listed under ‘How do I return this form to the NDIA’. You can also contact us if you want someone to do things for you with the NDIS or make decisions on your behalf.

You can give your consent to share information if you are an applicant, a participant, a child representative, plan nominee or legally appointed decision maker for an applicant or participant. When we say applicant, we mean someone who is applying to the NDIS.

We will only share your personal information if you have given us consent to or if we are required or authorised to disclose your information by law.

You can take away your consent at any time. You can let us know by mail, email, in person or over the phone that you no longer consent to us sharing information on your behalf.

How do I return this form to the NDIA?

There are a few ways you can return this form to us:

Email for applicants: NAT@ndis.gov.au

Email for participants: enquiries@ndis.gov.au

Mail: NDIA, GPO Box 700, Canberra ACT 2601

In person: Visit a local area coordinator, early childhood partner or NDIS office in your area.

Part A: Participant details

Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please complete this section about the participant you are representing.

First name

Last name

Date of birth

NDIS participant number

Contact Phone Number

Contact email

Address & Contact details(Address,Postcode, State,Country etc.)

Part B: Child representative, plan nominee, legally appointed decision maker details

Please provide your details in this section if you are completing this form on behalf of a participant:

under 18 years for whom you have parental responsibility, or a child representative
for whom you are a plan nominee, or
for whom you are a legally appointed decision maker (for example, a guardian).

Participant representative full name

Your Phone Number

Your Email

Relationship to participant/applicant

Your Date of Birth

Address & Contact details(phone number, email address, etc.)

Part C: Provide consent

Please complete the details of who you want to share your information with.

I consent to the NDIA giving information about me (or the participant/applicant I am representing who is identified in Part A of this form), to the following people and/or organisations.

3.1 Person and/or organisation 1

Key Contact Full name

Organisation

Position

Organisation Address

Phone

Email

Is the organisation an NDIS provider

If you answered 'Yes' to this question, do they provide NDIS supports to you?

3.1a Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation

My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service providers

My NDIS information

The assessments and reports held about me by the NDIAMy NDIA Access Request FormA copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals and AspirationsA copy of my current NDIS Plan’s funding and supportMy NDIS ContactA copy of all parts of my previous NDIS Plan/sA copy of my previous NDIS Plan/s Goals and AspirationsA copy of my previous NDIS Plan/s funding and support

Any other information

If so, please specify what this information is below:

3.1b Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

3.1c Please mark the relevant box below to indicate the length of time you are providing the consent for

Ongoing

For the duration of my current NDIS plan

For a set time ending (DD/MM/YYYY)

Once only

3.2 Person and/or organisation 2

Key Contact Full name

Organisation

Position

Organisation Address

Phone

Email

Is the organisation an NDIS provider

If your answer is Yes, do they provide NDIS supports to you?

3.2a Please mark the relevant boxes below to indicate the information you give consent to share with this person and/or organisation

My personal information

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service providers

My NDIS information

The assessments and reports held about me by the NDIAMy NDIA Access Request FormA copy of all parts of my current NDIS PlanA copy of my current NDIS Plan’s Goals and AspirationsA copy of my current NDIS Plan’s funding and supportMy NDIS ContactA copy of all parts of my previous NDIS Plan/sA copy of my previous NDIS Plan/s Goals and AspirationsA copy of my previous NDIS Plan/s funding and support

Any other information

If so, please specify what this information is below:

3.2b Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information

3.2c Please mark the relevant box below to indicate the length of time you are providing the consent for

Ongoing

For the duration of my current NDIS plan

For a set time ending (DD/MM/YYYY)

Once only

Part D: Your declaration

This part needs to be signed by whoever completed this form. This may be the participant/applicant, or child representative, plan nominee or legally appointed decision maker.

I confirm that:

I understand I can get further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. You can find this information on the NDIS website.
I understand I have given the NDIA consent to give information about me to the third party or parties I have listed at Part C on this form so they can take the identified action/s on my behalf.
I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time.
I confirm the information provided in this form is complete and correct.
I understand giving false or misleading information is a serious offence.
I understand this information is protected by law and can only be given to someone else where Commonwealth law allows, or requires it, or where I give permission.
You can find out more about how we collect, use and disclose your personal and sensitive information on our website (ndis.gov.au). Select ‘About’, then select ‘Policies’, then ‘Freedom of Information’, then ‘Privacy’ from the menu on the right.

Signature

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Name

Date