Service Agreement

Service Agreement Type *

Aged CarePrivate

St Johns Or Other

Please read this Service Agreement in full prior to signing and dating.

It contains important information in relation to the supports that will be provided.

Client Details

Client First Name *

Client Surname *

The Person that is Authorised to sign this Service Agreement is:

The Client? *

The Authorised Representative? *

Client's Authorised Representative *

and Practice Name

Contact Details

Client First Name

Client Surname

Client Date of Birth *

Phone Number *

Email Address *

Street Address *

City *

State *

Postcode *

Client' Representative Name

Client Representative Phone *

Client Representative Email *

Relationship to Client *

Supports to be provided:

Home Visit - Occupational Therapy Assessment, observations and home assessments

hours @ $180/hour

Report writing, correspondence and liaison, file review, documentation, client/carer interview

hours @ $180/hour

Client associated travel. Minimum charge is 30mins

hours

Client associated travel (in KM). Charged at $1 per KM

kms

TOTALS

Schedule of Supports

Please prepare my funding in: *

Update on Current Service Agreement for this Plan Period

Previous Therapy Used *

Occupational Therapy

Previous OT dollarsTotal of funds used so far by Propel OT in this Plan Period

Previously used OT hoursTotal hours used so far by Propel OT in this Plan Period

Service Start Date *

Services to be provided *

Occupational Therapy

Occupational Therapy Dollars *

Occupational Therapy Hours *

Total Funding (Dollars)

Total Funding (Hours)

Total BudgetInclusive of any Therapy funding used and requested in this Plan Period

Total HoursInclusive of any Therapy funding used and requested in this Plan Period

Total HoursInclusive of any Therapy hours used and requested in this Plan Period

Total DollarsInclusive of any Therapy hours used and requested in this Plan Period

Occupational Therapist *

OT Email *

Further Information regarding Private Schedule of Supports

What will Propel OT bill for:

Propel OT bill for the time our staff spend providing each service. Some examples are outlined below:

General

Propel OT will not bill for any contact visits or information provided before you sign.
Propel OT will bill for attending meetings or appointments for the participant, we charge for each person and their travel time.

Face-to-face Services:

Propel OT bill for your home visits or other appointments with us, including travel time for any staff who must travel to provide the service.

Other meetings and correspondence:

Propel OT will bill when we need to meet with, talk to or write to others about the capacity building of the Participant, this could include time spent (any task that takes more than 6 minutes will be invoiced):

Meeting with other members of the Participant's support team and employers,
Writing to or for the family or employer,
Sharing case notes or reports with external professionals,
Talking with those involved in an Individual Family Service Plan (IFSP),
Propel OT will not charge for our administrative team meetings.

Reports, research and resources:

Propel OT will charge for other capacity building work we do for the Participant outside of appointments, such as preparing reports and doing research.
Propel OT will charge for producing resources.

Propel OT reserves the right to NOT provide service or to cancel any future appointments for the Client if you do not have sufficient funds.

Price and Payment Information:

Occupational Therapy: $180.00 per hour plus $180.00 per hour for any associated therapist travel.

If any Propel OT Therapist arrives to a confirmed appointment, and the Client declines service, is not present or does not show up after contact attempts, then both non-attendance of the appointment and any relevant travel will be charged.

Travel

Note: Therapy services, reporting, correspondences and liaison cost will be based on Clinician's location at the time of providing services.

Full Schedule of services will be available after initial appointment from clinician upon request.
Travel claim includes any accommodation, fuel charges and provider travel time for Clinician.
If participant prefers to come to Propel hub on own or with participant's support worker, no provider travel costs will be charged.

Payments

Please note this an updated Service Agreement to include both previously used hours and further requested hours for the agreed funding period.

Propel OT will seek payment for their provision of supports after the supports have been delivered in accordance with the below information:

Payment is due by Electronic Funds Transfer within 7 days of invoicing.

All outstanding invoices must be paid before provision of next service.

Upon request of Assessment Report all services involved in completion of Report must be paid prior to Report being provided to the relevant Parties.

ABN: 32 640 251 449

Funding body *

Email for invoicing *

Reports

It is helpful for the Therapist to have a copy of relevant documentation (reports etc.). This ensures we are working towards your goals. It is your choice whether or not to provide copies of reports.

Report(s) / Other Document(s)

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Rights & Responsibilities

Propel OT agrees to:

Provide Therapy services as per this agreement.
Work in collaboration with you to achieve your goals.
Communicate openly and honestly with you.
Be polite and friendly and treat you with respect at all times.
Explain things clearly so you understand every step of the process.
Include you in all decisions about your supports.
Listen to your feedback and act quickly upon any complaints you report to us.
Store your information carefully and maintain your privacy

The Client/Client's Representative agrees to:

Notify Propel OT about any changes you wish to be made to this Service Agreement.
Provide at least 7 days notice if you wish to cancel a booked service.
Provide at least 2 weeks notice if you wish to terminate our services. You will be billed for the hours of service provided to the date of termination.
Pay invoices by the due date.

Cancellation Policy

Short notice cancellations or non-attendance, where notice is given with less than 7 days before the scheduled appointment, may result in 100% of the appointment fee being charged (except in extenuating circumstances), including any travel (or part thereof) already undertaken, unless there is capacity to fill the vacancy with other services (e.g. develop resources) for the Client.

Clients and/or their representative need to contact Propel OT by phone or email to cancel an appointment.

In the event that Propel OT needs to cancel the Client's appointment, there will be no charge to the Client and every attempt to contact the Client or their Representative will be made to minimise any inconvenience caused.

Propel OT will endeavour to make up this time by either extending subsequent appointments (if time allows) or rescheduling the appointment.

Making a Complaint

We will strive to ensure that your experience with Propel OT is a positive one, however in any instance where you are unhappy with our service, feel free to discuss this with us as soon as possible. Please be assured that we welcome all feedback and will endeavour to resolve any issues or concerns in a timely manner.

If you have a concern, you can speak directly to the Director:

David Mawere
E: feedback@propelot.com.au
P: 07 4724 3684

Changes to this Service Agreement

If changes to the supports or their delivery are required, the Parties agree to discuss and review this Service Agreement. The Parties agree that any changes to this Service Agreement will be in writing, signed, and dated by the Parties.

Ending this Service Agreement

Should the Client/Client's Representative or the Provider wish to end this Service Agreement they must give 2 weeks notice.

If the Client/Client's Representative or the Provider seriously breaches the terms in this Service Agreement, the requirement of notice will be waived.

Consent

At times, it may be helpful for us to talk with other people involved in your care. Only information relevant to the service we are providing will be discussed. We will not talk with anyone that you do not want us to speak with.

The Client/Client Representative consents to Propel OT specifically liaising with:

Case Manager

QLD Health Services

Other past and current health professionals

I (client/authorised representative) consent to:

Collection of personal information as detailed within the service agreement

Propel OT retaining information as required and stated within the service agreement

Sharing of personal information, as required, for provision of services

Photographs being taking and/or used for the purpose of documentation and reporting

Participating in the required auditing processes for regulation purposes

Signatures

Are all details correct? *

Yes - proceed to signing Service AgreementNo - please review and update

Review Notes *

By signing this Agreement, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Agreement and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this Agreement.

I have read & understood this Service Agreement and understand each item listed within. I understand Propel OT will be engaged to provide services that it is entitled to receive payment in return.

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Agreement as the Client's Authorised Representative.

Upload Purchase Order *

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Name of Approver *

Date

Thank you - we will review your response promptly and return an updated form for you to approve.

Please hit "Submit" button below to proceed.

Thank you - Please hit "Submit" button below to proceed.

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Propel OT Representative *

Date *

Send Signed Service Agreement to: *

ClientClient RepresentativeCase ManagerOther

Client Email Address

Client Representativeplease amend as required

Case Manager Email

Other Email

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