Registration Form

Assure Plan Management Registration

Thank you for choosing Assure Plan Management as your dedicated plan manager!
Signing up is quick and easy and only takes a few minutes.

Registration Form

Free Text

NDIS Participant details

Full name of NDIS Participant*

Date of Birth*

Address, including state and postcode*

Participant's phone number*

Gender

Email Address*

Free Text

NDIS plan details

NDIS Number*

Plan Start Date (if known)

Plan End Date (if known)

If you have a copy of your NDIS plan, please attach it below

Upload File

Please select your preferred invoice approval method*:

Auto approve (We will process/pay all invoices without contacting you first)

Email approval (We will email you a copy of each invoice before making payment)

SMS approval (We will text you a summary of each invoice before making payment)

Free Text

NDIS Nominee or Child Representative (if applicable)

If you have a NDIS nominee, please list their contact details below

Nominee name

Nominee phone number

Nominee email address

Free Text

Support Coordinator (if applicable)

If you have a Support Coordinator (SC), please list their contact details below

SC Name*

SC Phone Number*

SC Email Adress*

Free Text

Primary contact person

You may have listed a few different people above. Who should we first contact if we need to get in touch? This person will receive all general communication from us.

Primary Contact Name*

What is this person's relationship to the Participant (parent, sibling, friend etc)?*

What is this person's preferred method of contact? *

Phone

Free Text

Final steps...

Please let us know any other important information about you or your disability, that can help us to best service your needs

Opt-In

By submitting this form, you acknowledge that your information will be stored securely and used in line with our Privacy Policy.*