Orthomotion New Client Service Agreement

We look forward to seeing you at Orthomotion

Please complete the Orthomotion New Client Service Agreement Form at least seven days prior to an initial assessment consultation with us.

This client service agreement provides agreement for Orthomotion to deliver orthotic services to you ('the client') for an initial assessment consultation, reporting activities and other services required to meet your mobility requirements and goals.

Orthomotion cannot proceed with an initial assessment appointment without receiving your completed client service agreement.

Please contact our team on (02) 9055 5300 if you have any queries regarding the completion of the service agreement.

* Denotes mandatory field

Today’s date *

Who is completing this service agreement? *

I am completing this form on behalf of myself as the client specified in the ‘Client Information’ section of this formI am completing this form on behalf of the client specified in ‘Client Information’ section

My email address to receive a copy of this service agreement *

First name *

Last name *

Phone (preferred contact) *

Phone (alternative contact)

Email (a copy of the completed service agreement will be sent to this email address) *

My relationship with the client is *

Other - please specify: *

Client Information

First name *

Last name *

Title

Date of Birth *

Phone (preferred contact) *

Phone (alternative contact)

Email *

Client Diagnosis / Condition

Please specify: *

Diagnosis/condition name:

Orthomotion Services & Client Funding

Funding Other

NDIS participant

NDIS number *

NDIS Plan dates – start date *

NDIS Plan dates – end date *

EnableNSW

EnableNSW provides funding for assistive technology supports/aids (‘equipment’), such as AFOs and orthopaedic footwear, and some services associated with the delivery of supports via an approval process. EnableNSW does not provide funding for Orthomotion services such as initial assessment consultations, ongoing review appointments and reporting activities required to seek funding approval for supports. Orthomotion clients with EnableNSW funding are required to pay Orthomotion directly for all services delivered to them that are not covered by EnableNSW funding.

Orthomotion services

The following services are included within this service agreement and will only be delivered to the client as required.

Please note: services that are delivered to the client will be invoiced for payment. Services that are not delivered to the client will not be invoiced for payment.

I agree to Orthomotion delivering the following services to the client as part of this service agreement: *

✓ Initial Assessment Consultation: (minimum 2 hours) $387.98*

✓ Casting appointment & casting materials: (if clinically recommended) calculated at hourly rate of $193.99* + associated casting materials (Low Cost AT)

✓ AT device trial appointment: (if clinically recommended) calculated at hourly rate of $193.99*

✓ Cancellation Service fee: applied for short notice or 'no-show' appointments if less than two (2) business days notice is given for appointment changes and cancellations, and if client is more than 30 minutes late to their scheduled appointment time; 100% of appointment cost calculated at hourly rate of $193.99*

✓ Clinical Case Management: (as required) calculated at hourly rate of $193.99*

✓ Low & Mid-Cost AT written evidence (orthotic supports) and quote specifying recommended supports and services: (mandatory NDIS requirement, maximum two reporting hours) calculated at hourly rate of $193.99*

✓ High-Cost AT assessment (P-O-AT) and quote specifying recommended supports and services: (mandatory NDIS requirement, maximum four reporting hours) calculated at hourly rate of $193.99*

Subsequent service agreements will be created between Orthomotion and the client as required to specify the recommended orthotic supports and services to be delivered the client by Orthomotion.

*NDIS support budget: Capacity Building - Improved Daily Living

✓ Initial Assessment Consultation: (minimum 2 hours) $387.98

✓ Casting appointment & casting materials: (if clinically recommended) calculated at hourly rate of $193.99 + associated casting materials

✓ AT device trial appointment: (if clinically recommended) calculated at hourly rate of $193.99

✓ Cancellation Service fee: applied for short notice or 'no-show' appointments if less than two (2) business days notice is given for appointment changes and cancellations, and if client is more than 30 minutes late to their scheduled appointment time; 100% of appointment cost calculated at hourly rate of $193.99*

✓ Clinical Case Management: (as required) calculated at hourly rate of $193.99

✓ Orthotic assessment report & quote for recommended supports and services: (as required) to seek funding for recommended supports) calculated at hourly rate of $193.99

Subsequent service agreements will be created between Orthomotion and the client as required to specify the recommended orthotic supports and services to be delivered the client by Orthomotion.

✓ Initial Assessment Consultation: (minimum 2 hours) $387.98

✓ AT device trial appointment: (if clinically recommended) calculated at hourly rate of $193.99

✓ Cancellation Service fee: applied for short notice or 'no-show' appointments if less than two (2) business days notice is given for appointment changes and cancellations, and if client is more than 30 minutes late to their scheduled appointment time; 100% of appointment cost calculated at hourly rate of $193.99*

✓ Clinical Case Management: (as required) calculated at hourly rate of $193.99

✓ Orthotic assessment report & quote for recommended supports and services: (provided to EnableNSW to seek funding for recommended supports; maximum two reporting hours) calculated at hourly rateof $193.99

Subsequent service agreements will be created between Orthomotion and the client as required to specify the recommended orthotic supports and services to be delivered the client by Orthomotion.

✓ Initial Assessment Consultation: (minimum 2 hours) $387.98

✓ Casting appointment & casting materials: (if clinically recommended) calculated at hourly rateof $193.99 + associated casting materials

✓ AT device trial appointment: (if clinically recommended) calculated at hourly rate of $193.99

✓ Cancellation Service fee: applied for short notice or 'no-show' appointments if less than two (2) business days notice is given for appointment changes and cancellations, and if client is more than 30 minutes late to their scheduled appointment time; 100% of appointment cost calculated at hourly rate of $193.99*

✓ Clinical Case Management: (as required) calculated at hourly rate of $193.99

✓ Orthotic assessment report & quote for recommended supports and services: (as required to seek funding for recommended supports) calculated at hourly rateof $193.99

Subsequent service agreements will be created between Orthomotion and the client as required to specify the recommended orthotic supports and services to be delivered the client by Orthomotion.

Funding & payment arrangements

How funding is managed to pay for Orthomotion supports and services delivered to the client

I agree to provide payment to Orthomotion for all services delivered to the client, including the cancellation fee, as per the specified services and service fees outlined in this service agreement. *

I agree that the client funding information provided in this agreement is correct at the time of completing this service agreement *

I agree that it is the client's responsibility to notify Orthomotion if funding arrangements change and that the client is liable for any outstanding payments as per an Orthomotion invoice if funding arranagments changed and I did not notify Orthomotion *

Core Budget – Consumables *

Self-managed: The client pays Orthomotion directly for all supports and services delivered to them by Orthomotion as specified in an Orthomotion invoicePlan-managed: The client's nominated plan manager pays Orthomotion directly (on client's behalf) for the supports and services delivered to the client as specified in an Orthomotion invoiceNDIA/Agency-managed: Orthomotion will create a service booking in the NDIS portal for the total cost of supports and services to be delivered to the client and will complete a payment request for the total amount as specified in an Orthomotion invoiceNDIA/Agency-managed with NDIS plan on PACE: Orthomotion will submit a payment request/claim to the NDIA for the total amount of the client's Orthomotion invoice. The client must record/endorse Orthomotion as one of their ‘my providers’ for their current NDIS plan prior to Orthomotion providing services. Clients can contact the NDIA National Call Centre on 1800 800 110 or their ‘my NDIS contact’ to advise that they endorse Orthomotion as a 'my provider’.

Plan Manager organisation name *

Plan Manager email address *

Plan Manager phone number *

Capacity Building Budget – Improved Daily Living *

Self-managed: The client pays Orthomotion directly for all supports and services delivered to the client by Orthomotion as specified in an Orthomotion invoicePlan-managed: The client's nominated plan manager pays Orthomotion directly (on client's behalf) for the supports and services delivered to the client as specified in an Orthomotion invoiceNDIA/Agency-managed: Orthomotion will create a service booking in the NDIS portal for the total cost of supports and services to be delivered to the client and will complete a payment request for the total amount as specified in an Orthomotion invoiceNDIA/Agency-managed with NDIS plan on PACE: Orthomotion will submit a payment request/claim to the NDIA for the total amount of the client's Orthomotion invoice. The client must record/endorse Orthomotion as one of their ‘my providers’ for their current NDIS plan prior to Orthomotion providing services. Clients can contact the NDIA National Call Centre on 1800 800 110 or their ‘my NDIS contact’ to advise that they endorse Orthomotion as a 'my provider’.

Plan Manager organisation name *

Plan Manager email address *

Plan Manager phone number *

Capital Budget – Assistive Technology *

Self-managed: The client pays Orthomotion directly for all supports and services delivered to the client by Orthomotion as specified in an Orthomotion invoicePlan-managed: The client's nominated plan manager pays Orthomotion directly (on client's behalf) for the supports and services delivered to the client as specified in an Orthomotion invoiceNDIA/Agency-managed: Orthomotion will create a service booking in the NDIS portal for the total cost of supports and services to be delivered to the client and will complete a payment request for the total amount as specified in an Orthomotion invoice.NDIA/Agency-managed with NDIS plan on PACE: Orthomotion will submit a payment request/claim to the NDIA for the total amount of the client's Orthomotion invoice. The client must record/endorse Orthomotion as one of their ‘my providers’ for their current NDIS plan prior to Orthomotion providing services. Clients can contact the NDIA National Call Centre on 1800 800 110 or their ‘my NDIS contact’ to advise that they endorse Orthomotion as a 'my provider’.

Plan Manager organisation name *

Plan Manager email address *

Plan Manager phone number *

Privacy consent form

Orthomotion will collect, retain, use and disclose the personal and health information provided on this form for the primary purpose of providing orthotic supports and services. All records and results are kept in accordance with relevant Commonwealth and State law. Orthomotion can only provide services to the person seeking orthotic services and supports from Orthomotion by collecting, retaining, using and disclosing the personal health information on this form.

I hereby give consent for my/my client’s personal health information to be collected, stored and used for the purpose of Orthomotion providing orthotic supports and services and for my personal health information to be disclosed to third parties involved in my healthcare, such as referring health professionals, and relevant funding agencies. *

I agree that I have provided consent to the collection, storage, use and disclosure of my personal health information on a voluntary basis. *

I hereby give consent for my personal health information obtained in assessment and treatment sessions on paper, electronically, video and audio recordings, to be used for clinical, teaching and research purposes, understanding that my identity will be kept confidential at all times. *

YesNo

I hereby give consent for ORTHOMOTION to use and publish my personal health information in promotional materials or other forms of media, without notification, understanding that my identity will be kept confidential at all times. *

YesNo

I hereby give consent for ORTHOMOTION to directly contact me regarding future clinical, teaching, research and publishing purposes *

YesNo

I have read and understand the information above and I know that I can withdraw my consent at any time without affecting the care I receive from ORTHOMOTION. I know that I can request a copy of this form to keep at any time. *

YesNo

Terms and Conditions

You are required to read the ORTHOMOTION TERMS AND CONDITIONS document prior to receiving supports and services from Orthomotion. The Terms and Conditions document provides clear information regarding our services, AT supports, fees and business processes which apply to you in all your interactions with Orthomotion as an Orthomotion client.

I have read and agree to the ORTHOMOTION TERMS AND CONDITIONS (click to view) *

Service Agreement Validity

The new client service agreement will be valid for 90 days from the date submitted to Orthomotion. A new Orthomotion New Client Service Agreement form may be required to be completed if initial assessment services have not been commenced within a 90 day period.

I agree that this service agreement is valid for 90 days from the date this form was submitted to Orthomotion. *