Consent to share your 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.

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Part A: Applicant/participant details

Full name
Date of birth (DD/MM/YYY)
NDIS number
Contact phone number
Contact email

If you are the applicant or participant, go to Part C.

If you are a child representative, plan nominee or other legally appointed decision maker, complete Part B then Part C.

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 the applicant or participant:

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

Full name
Date of birth (DD/MM/YYY)
Contact phone number
Contact email
Relationship to participant/applicant e.g. child representative, plan nominee, legally appointed decision maker
Employee number or logon (if you are completing this form as part of your job)

Part C: Provide consent

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

If there are more people or organisations you want to give consent to, you can include them as a list when sending this form back to us.

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.

Person/organisation 1

Please mark the correct box and complete the details below.

☐ Person

☒ Organisation

First name	Sunday
Surname	Ehigie
Position Title (if applicable)	Principal Plan Manager
Organisation name (if applicable)	Optimum Plan Management Id: 4050062444
Phone	1300 607 404
Email	admin@optimumpm.com.au
Address (include street or PO Box number, suburb, state and postcode)	P O Box 197, Dingley Village VIC 3172
Relationship to participant/applicant	NDIS Plan Manager

We will share all of your information with the person or organisation you have chosen, unless you let us know what you don’t want us to share.

Information you don’t want us to share

If any, please choose the information you don’t want us to share:

My personal information

☐ My name, date of birth, NDIS participant number and NDIS participant status

☐ My address, email and phone number

☐ Details about my carers

☐ Details about my informal supports

☐ Details about my service providers

My NDIS information

☐ Assessments and reports the NDIA holds about me

☐ My NDIS application form

☐ The outcome of my NDIS application

☐ If I am found eligible for the NDIS, confirmation of when my first plan is approved

☐ A copy of all parts of my current NDIS plan

☐ A copy of my current NDIS plan’s goals and aspirations

☐ A copy of my current NDIS plan’s funding and support

☐ Who my NDIS contact is and how to contact them

☐ A copy of all parts of any previous NDIS plans

☐ A copy of any previous NDIS plan goals and aspirations

☐ A copy of any previous NDIS plan funding and support

Any other information

☐ If so, please tell us what this information is below:

Why do you want us to share your information?

We need to know you understand how the information we share will be used by the other person or organisation.

Please tell us why you want to share your information below:

For my plan manager to function effectively in providing with plan management services

For my plan manager to function effectively in providing with plan management services

How long are you providing consent for?

☒ Until further notice

☐ Until a set date (DD/MM/YYYY): ____________

☐ One time 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
Name
Date (DD/MM/YYY)