PARTICIPANT DETAILS Sample Clauses

PARTICIPANT DETAILS. (Please complete all fields in this section.)

PARTICIPANT DETAILS. Name: Click or tap here to enter text. Date of Birth: Click or tap to enter a date. NDIS Plan Start Date: Click or tap to enter a date. NDIS Plan End Date: Click or tap to enter a date. Address: Click or tap here to enter text. Mobile: Click or tap here to enter text. Email: Click or tap here to enter text. ☐ Acquired brain injury ☐ Psychosocial disability ☐ Austism ☐ Spinal cord injury ☐ Cerebral Palsy ☐ Stroke ☐ Hearing impairment ☐ Vision impaired ☐ Intellectual Disability, Developmental delay, Global developmental delay, Down Syndrome ☐ Multiple Sclerosis Other: Click or tap here to enter text. Does the participant have a mobility aid? ☐ Yes ☐ No If answered yes, please provide more information: Click or tap here to enter text. Does the participant require assistance in and out of the vehicle? ☐ Yes ☐ No Have the participants goals been recorded in a Participant Statement? ☐ Yes ☐ No Does the participant have an Epilepsy Management Plan? ☐ Yes ☐ No Does the participant have a Behavioural Support Plan? ☐ Yes ☐ No If answered yes to the any of the above, please provide this information as it will help us give you the best quality personalised service. Will there be any other person/s accompanying the participant? ☐ Yes ☐ No Will a companion animal be accompanying the participant? ☐ Yes ☐ No If answered yes to either of the above, we require companion forms to be signed. Support worker preference? ☐ Female ☐ Male ☐ Both Participant’s likes, dislikes, interests, hobbies etc.: Click or tap here to enter text. General notes of the participant: Click or tap here to enter text. (Please include - but not limited to - history of challenging behaviours, seizures, substance, or drug abuse)

PARTICIPANT DETAILS. Please make sure these details are the same as what the NDIS has on file. ☐ YES Gender: Post Code: NDIS Plan End Date: ☐ NO ☐ Social Media ☐ Google Search ☐ Telemarketing ☐ Word of Mouth ☐ Support Coordination Referral ☐ Email ☐ Event ☐ Other (please state): ☐ Phone ☐ SMS ☐ Email ☐ Easy English

PARTICIPANT DETAILS. 31) Study population (include number overall and per site expectation) Participants from MNR-MC: Version No. Effective Date Page 32) Will the participants be from any of the following groups? (tick as appropriate) 33) Will participants receive any payment or other incentives to participate, and how much? ☐ Yes Amount to be received per visit ☐ No

PARTICIPANT DETAILS. Name of Company: (hereinafter referred to as "the Participant”) Address: Postal Code: Company Registration Number: Please note that the above details will be used for billing and the reimbursement of grant provided. This must match the details of the participating company in the participation form. If billing and reimbursement are to be made to another company, proof of inter-billing (invoice and bank statement) must be provided.

PARTICIPANT DETAILS. Name of Participant Taxpayer ID # Address City State Zip E-mail address Telephone Number

PARTICIPANT DETAILS. Note: If you are not the participant and you are the participant’s chosen Nominated Representative, child representative, plan nominee or legally appointed decision- maker, please complete this section about the participant you are representing. Participant Name: NDIA Number: Plan Start Date: Plan End Date: How is your plan managed? ☐ Self-Managed ☐ Plan Managed ☐ NDIA Managed Date of Birth: Gender: Address: State: Phone Number: Email Address: Alternative / Emergency Contact Name Relationship to participant Alternative / Emergency Contact Number Please mark the relevant box with an X below to indicate your relationship to the participant: ☐ Parent and / or Child Representative ☐ Plan Nominee ☐ Legally Appointed Decision Maker Relationship to participant verified ☐ NDIA Portal ☐ NDIA Plan ☐ Other documentation Representative Name Preferred Contact Number Email Address How do you represent the participant? (If you are not a Child Representative) ☐ All matters relating to this Service Agreement ☐ All matters relating to the Support Plan ☐ All matters relating to support services on an ongoing basis Are you the participant’s Emergency Contact ☐ Yes ☐ No Intermediary type ☐ Plan Manager ☐ Support Coordinator ☐ Other Relationship to participant verified ☐ NDIA Portal ☐ NDIA Plan ☐ Verbal Provider Business Name Preferred Contact Person Phone Email What information can we obtain or share to support your entry to our service? ☐ All matters relating to this Service Agreement ☐ All matters relating to the development of my Support Plan ☐ All matters relating to support services on an ongoing basis Do you want us to check with you before we share information with this business/person? ☐ Yes ☐ No need Is there anything we should know about working with this Intermediary. effectively? Other organizations, or people in your network Mission You Pty Ltd may be in contact withto establish this Service Agreement and the Support Plan (people other than your Intermediaries provided earlier) Service Provider or Person’s Name Service Type / Relationship Consent to share information? Comments Actions Mission You Pty Ltd Hypnotherapy and Counselling Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Would you like to provide more detail about the kinds of information we can share? ☐ My name, date of birth, NDIS participant number and status ☐ My address, email, and phone number ☐ Details about my nominated support person ☐ Details about my service providers ☐ Assessment and reports held ...

PARTICIPANT DETAILS. The Participant is a legal entity that is a health information custodian (“HIC”) providing health care services through the site(s)/program(s)/service(s) it operates in the Ontario Health West Region, to be listed in Part 2 of this Agreement. Primary Business Address Suite/Unit/Floor City/Town Postal Code (e.g. K1A0B1) Business Telephone (e.g. 0000000000) Business Fax (e.g. 0000000000) Is the legal entity identified in Part 1 above a health information custodian within the meaning of the Personal Health Information Protection Act, 2004 (PHIPA)? Legal Entity Type (select the appropriate classification): If Legal Entity Type is Other, or Created Under Statute, please explain:  Please provide required information about each site and/or program/service owned and/or operated by the legal entity identified in Part 1 for which you are seeking approval to access ClinicalConnect  “Location/Office Name” should be the usual/common name applied to the site where health care is provided (e.g. ABC Pharmacy, or XYZ Family Health Team)  If you have more than a total of five sites, you must email the same details about each additional site to xxxx@xxxxxxxxxxxxxxx.xx which will be added to your application.  Normally, only sites or programs operating in LHINs 1-4 (Ontario Health West Region) qualify for access to ClinicalConnect. Program/Service Name (if applicable) HIC Type Street Address City Postal Code (e.g. K1A0B1) Phone (e.g. 0000000000) LHIN the site/program is located in Program/Service Name (if applicable) HIC Type Street Address City Postal Code (e.g. K1A0B1) Phone (e.g. 0000000000) LHIN the site/program is located in Program/Service Name (if applicable) HIC Type Street Address Postal Code (e.g. K1A0B1) Phone (e.g. 0000000000) LHIN the site/program is located in Program/Service Name (if applicable) HIC Type Street Address City Postal Code (e.g. K1A0B1) Phone (e.g. 0000000000) LHIN the site/program is located in Program/Service Name (if applicable) HIC Type Street Address City Postal Code (e.g. K1A0B1) Phone (e.g. 0000000000) LHIN the site/program is located in Select which type of credentials will be used to access ClinicalConnect upon approval of your organization as a Participant. Please note: ONE ID is currently the requisite Identity Provider if you wish to gain access to data from provincial repositories using ClinicalConnect.

PARTICIPANT DETAILS. This is the person receiving the NDIS funding. Nominated support person