CONSENT TO SHARE INFORMATION

This form confirms authority by participants for Plan Managers to discuss personal information about their plan with additional parties, if necessary.

Only the participant, their guardian or authorised representative may give consent to share. The information shared with us may include current plan details or budget amounts, details of other providers who have been engaged, participant details and representative contact details. Participants can also specify what they do and don’t want to share.

Giving Mode consent to access your personal information is purely optional and will not affect our service to you although some information is necessary for us to carry out our services whether consent to share is granted or not. Names may be added or removed and consent to share may be withdrawn at any time.

Name
Address
Post Code	Phone number
NDIS Number
Plan Dates
Plan Manager and/or Agency
Case Support Coordinator and/or Agency

Name of Mode Support Service/s	Choose an item.	Choose an item.	Choose an item.
If ‘Other Modification’, please describe:

DECLARATION:

I, [participant’s or authorised person’s name]: consent to Plan Managers and/or Support Coordinators sharing information about my/the NDIS plan to Mode Group.

Please tick the relevant information to share:

☐	My name, date of birth, NDIS participant number, NDIS participant status & plan dates

☐	My address, email, phone number

☐	A copy of my current NDIS Plan Goals and Aspirations

☐	A copy of my current NDIS Plan funding and support

Signature of Participant:	Date:

Signature of Delegate if applicable:	Date:

Information shared with Mode Group will be kept in strictest confidence and used only for the delivery of services to participants.