Request For Service | MOIRA | Youth, Disability, Family

Thank you for choosing MOIRA Financial Plan Management.
Follow the simple steps below to get started.

If you need help at any point during this sign up please contact fpmengagement@moira.org.au or call the team on 1300 666 472 for assistance.

Please note that all fields marked with an asterisk (*) are required to continue.

Are you signing up for yourself or on behalf of an NDIS participant? *

Completing for myself

Completing on behalf of an NDIS participant

Please specify*

First Name*

Last Name*

Phone Number

Email Address*

Participant Details

First Name*

Last Name*

Street Address*

Suburb*

Postcode*

State*

Phone Number*

Email Address*

Date of Birth (DD/MM/YYYY)*

Day*

Month*

Year*

NDIS Number*

Plan Management service information:

Plan management services are charged directly against a Participant’s NDIS Plan and in line with the NDIS Price Guide under the Support Category: Capacity Building - Improved Life Choices and following stated line items.

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 plan administration	Improved Life Choices - Improved Life Choices - Capacity building and Training in Plan and Financial Management by a Plan Manager	14_031_0127_8_3

The above support items are subject to price limits.
To view these price limits, please visit the latest NDIS Price Guide on the NDIA Website.

There is no out pocket cost incurred by the participant.

Does the Participant have an Authorised Representative?*

Yes

Authorised Representative Details

Authorised Representative 1

First Name*

Last Name*

Please specify relationship*

Pre-fill using Participant details above

Street Address

Suburb

Postcode

State

Phone Number*

Email Address*

+ Add additional representative

Add additional representatives to communicate and authorise invoices on behalf of the NDIS Participant. A maximum of three additional contacts can be added.

Does the Participant have a Support Coordinator?*

Yes

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

Upload your NDIS Plan (Optional)

MOIRA requests a copy of your NDIS plan to review and confirm the support areas and funding available.
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 Service Agreement to:

Participant

Authorised representative

Alternative contact

Alternative Contact Details

Name*

Phone*

Email*

Relationship to NDIS participant*

Submitting without uploading your NDIS plan may delay the sign up process and our ability to support your plan.

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MOIRA Financial Plan Management

Participant Details

Authorised Representative Details

Authorised Representative 1

Support Coordinator Details

Upload your NDIS Plan (Optional)

Alternative Contact Details

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