QDMS Reimbursement Request Form

Participant Information

Given Name *

Surname *

Date of Birth *

NDIS number

Email Address

Phone Number

Reimbursement Details

Does the tax invoice/receipt show the business' ABN?

YesNo

Was the item purchased from overseas? *

YesNo

Please provide a copy of payment receipt or bank statement showing AUD amount paid. *

Please email: accounts@qdms.com.au for further advice.

Does the tax invoice/receipt include a description of the purchase/support? *

YesNo

In line with NDIS Payment Assurance requirements, receipts should contain a description of the item/support purchased. If you need further information, please contact QDMS at: accounts@qdms.com.au

Does the tax invoice/receipt clearly show the date of purchase/date the support was provided? *

YesNo

In line with NDIS Payment Assurance requirements, the date of purchase/support must be included on the receipt. If you need further information, please contact QDMS at: accounts@qdms.com.au

Have you paid for this item/support from your own personal funds? *

YesNo

Please ensure you retain proof of purchase/payment as you may be requested to provide this if the claim for reimbursement is audited by the NDIA in the future. If you need further information, please contact QDMS at: accounts@qdms.com.au

Have you provided QDMS with your bank details previously? *

YesNo

Account Name *

BSB *

Account Number *

IMPORTANT: Please ensure you have provided an email address above so we can send you a payment remittance advice.

What is the total amount you are seeking reimbursement for? *

Please attach receipt *

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Additional information (if applicable)For example, if there are multiple items on an invoice, please indicate which items are to be reimbursed.

Participant Declaration

By signing and submitting this form you are acknowledging that the reimbursement you are requesting for the purchase of an item, support or service is:

directly related to the disability for which you were granted access to the National Disability Insurance Scheme,
relates to the goals in your NDIS plan,
has been funded in your plan,
not a support that cannot be funded by NDIS, and
in line with NDIS rules, guidelines and legislation including the NDIS Support Lists.

NDIS Support Lists can be found on the NDIS website: https://ourguidelines.ndis.gov.au/would-we-fund-it/what-does-ndis-fund

If you are unsure whether your purchase meets the NDIS guidelines and legislation, you can find further information on the NDIS website here: www.ndis.gov.au - Does the support meet the reasonable and necessary criteria?

Some items purchased with NDIS funding may require a report, recommendation or supporting evidence to be provided or kept on file. This documentation may be requested by the NDIA. Please ensure you keep a record of the required documentation for these purchases, further information can be found here: www.ndis.gov.au/participants/assistive-technology-explained

If you need some further guidance you can also contact QDMS at: accounts@qdms.com.au

Please check this box after you have read the Participant Declaration above to confirm you understand your responsibilities as an NDIS participant when purchasing supports, services and items. *

Signature of participant or participant's representative *

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Name *

Date *