Complete Choice

0414 890 464 / 0466 057 770

info@completechoice.com.au

39 John St, Salisbury, SA 5108

F41 Consent Third Party to Act DOCX

F41 Consent Third Party to Act DOCX

Consent for a third party to act on your behalf
Please use this form to give your permission (consent) to another person or an organisation
(third party) to do things for you with the NDIS.
There are 4 parts to this form (A, B, C, and D). Depending on your situation, you will not
have to complete each part. We have provided instructions for you throughout the form.
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 give your consent for someone to act on your behalf if you are an applicant, a
participant, a child representative, a plan nominee or legally appointed decision maker for
the applicant or participant. When we say applicant, we mean someone who is applying to
the NDIS.
We will only let another person or organisation do things for you with the NDIS if you have
given us consent 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 for a third party to do things for you with the
NDIS.
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.

Part A: Applicant/participant details

Please complete Part A with the details of the person who is giving consent.

Full name
Full name
First
Last

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).
The NDIA may ask you to provide information to confirm you are authorised to represent the
participant or applicant and to verify your identity.

Full name
Full name
First
Last

Part C: Third party details and consent

Details of who you want to give consent to
Please complete the details of the persons/organisations you want to give consent to act on
your behalf below.
You can provide the details of up to two people and/or organisations. 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 below persons/organisations to act on my behalf:
Person/organisation 1

Please mark the correct box and complete the details below.
Name
Name
First
Last
Address (include street or PO Box number, suburb, state and postcode).
Address (include street or PO Box number, suburb, state and postcode).
House / Street
suburb
City
State/Province
Zip/Postal
Country

What would you like the above person/organisation to do on your behalf?

Please mark the boxes that apply to you.
How long are you providing consent for?

Person/organisation 2

Please mark the correct box and complete the table below.
Name
Name
First
Last
Address (include street or PO Box number, suburb, state and postcode).
Address (include street or PO Box number, suburb, state and postcode).
House / Street
suburb
City
State/Province
Zip/Postal
Country

What would you like the above person/organisation to do on your behalf?

Please mark the boxes that apply to you.
How long are you providing consent for?

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.

Maximum file size: 15MB