Request For Service | MOIRA | Youth, Disability, Family

Thank you for choosing MOIRA Financial Plan Management.

We're here to help you make the most of your NDIS Plan. Getting started is easy. Simply follow the steps below.

Please contact us on fpmengagement@moira.org.au or 1300 666 472 for assistance.

Please note fields marked with an asterisk (*) require completion.

Let us know who you are:*

I am the NDIS Participant

I am completing on behalf of a NDIS Participant

Please specify*

First Name*

Last Name*

Phone Number*

Email Address*

NDIS Participant Details

Please ensure Participant details matches the information provided to the NDIA.

First Name*

Last Name*

Street Address*

Suburb*

Postcode*

State*

Phone Number*

Email Address*

Date of Birth (DD/MM/YYYY)*

Day*

Month*

Year*

NDIS Number*

Does the Participant have an Authorised Representative?*

Yes

Authorised Representative Details

The Authorised Representative/s will be authorised to approve invoices for payment and handle financial matters on behalf of the Participant. Authorised Representatives are expected to be independent and free from conflict.

Authorised Representative 1

First Name*

Last Name*

Please specify relationship*

Pre-fill using Participant address above if it is the same

Street Address

Suburb

Postcode

State

Phone Number*

Email Address*

+ Add additional representative

Does the Participant have a Support Coordinator?*

Yes

Is the Support Coordinator also an Authorised Representative^?

Yes

^An Authorised Representative can approve invoices for payment and handle financial matters on behalf of the Participant.

Support Coordinator Details

First Name*

Last Name*

Phone Number*

Email Address*

Who will authorise invoices on behalf of the Participant (select all that apply)?

Participant

Authorised representative

Support Coordinator

Plan Management service information:

Plan management services are charged directly against a Participant’s NDIS Plan and in line with the NDIS Pricing Arrangements and Price Limits document. There is no out-of-pocket cost incurred by the participant.

Fee	NDIS Category	Reference Number
Establishment fee	Improved Life Choices - Plan Management and Financial Capacity Building	14_033_0127_8_3
Ongoing Maintenance Fee	Improved Life Choices – Plan Management - Financial Administration monthly processing	14_034_0127_8_3
Capacity Building and Training in Self-Management and Plan Management	Core Supports – Assistance with Daily Life (Daily Living)	01_134_0117_8_1

Upload your NDIS Plan (Optional)

MOIRA requests a copy of your NDIS plan to review, confirm the support areas and the available funding.
Privacy Policy

Click here to upload your NDIS plan File types accepted include .pdf, .doc, .docx, .xlsx & .xls. Max size 10mb. Upload is not mandatory but strongly encouraged.

If you do not have a copy of your NDIS plan or are experiencing difficulty in uploading your plan please contact fpmengagement@moira.org.au or call 1300 666 472 for assistance.

Please specify*

Please email the MOIRA Plan Management Service Agreement to (select all that apply):

Participant

Authorised representative

Alternative contact

Alternative Contact Details

Name*

Phone*

Email*

Relationship to NDIS participant*

By submitting this request for plan management, you agree MOIRA may make a service booking in the NDIS Portal. You also agree MOIRA may use your details to access your NDIS plan.

If you provide MOIRA with a copy of your formal NDIS plan, you can avoid delays in the sign-up process and assist MOIRA to fully support your NDIS Plan.

We will contact you within 48 hours (usually next business day) with our Plan Management Service Agreement. We will give you information about the next steps to access your NDIS plan information on the MOIRA Plan Management Portal, and how to submit invoices to be processed by us.
MOIRA will not process any claims and payments of invoices until the Service Agreement is signed.

Please refer to MOIRA’s Privacy Statement on how we collect, use, manage and store your personal information.

We look forward to having you on board with our Plan Management team.

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NDIS Participant Details

Authorised Representative Details

Authorised Representative 1

Support Coordinator Details

Upload your NDIS Plan (Optional)

Alternative Contact Details

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MOIRA Financial Plan Management