Document text
Request for Internal Review of an NDIA Decision
Full name: [YOUR FULL NAME]
NDIS number (if any): [NDIS NUMBER]
Date of birth: [DATE OF BIRTH]
Address: [YOUR ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
Nominee or representative (if any): [NAME AND RELATIONSHIP]
To: National Disability Insurance Agency
[ADDRESS OR EMAIL FROM YOUR DECISION NOTICE]
[DATE]
Request for internal review under section 100 of the National Disability Insurance Scheme Act 2013 — decision dated [DATE OF DECISION]
Dear Sir or Madam,
I am directly affected by the decision dated [DATE OF DECISION], which I received on [DATE RECEIVED]. I ask for an internal review of it.
The decision
( ) Decision that I do not meet the access criteria.
( ) Decision to approve the statement of participant supports in my plan dated [PLAN DATE].
( ) Decision to vary, or not to vary, my plan.
( ) Other: [DESCRIBE THE DECISION].
What I ask the reviewer to change
[FOR EXAMPLE: include [NUMBER] hours a week of [SUPPORT TYPE], costed at $[AMOUNT] a year / find that I meet the disability requirements].
Why
[EXPLAIN IN YOUR OWN WORDS: your disability, what you cannot do without the support, what happened since the decision, and what the decision missed or got wrong. Refer to the evidence below.]
Evidence enclosed
[REPORT FROM [TREATING DOCTOR / SPECIALIST], DATED [DATE]]
[FUNCTIONAL CAPACITY OR THERAPY REPORT FROM [ALLIED HEALTH PROFESSIONAL]]
[LETTER FROM SUPPORT WORKER, CARER OR SCHOOL]
[OTHER EVIDENCE]
I make this request within 3 months after receiving the notice. Please ensure the review is done by someone not involved in the original decision, contact me on [PHONE] if you need more information, and send me the review decision with reasons in writing.
Yours faithfully,
____________________
[YOUR FULL NAME]
For me
[ ] Notice received: [DATE]; 3 months ends [DATE]
[ ] Request sent on: [DATE], how: [EMAIL / POST / PHONE, NAME OF STAFF MEMBER]
[ ] Decision due within 90 days of the request: [DATE]
[ ] If I still disagree: Administrative Review Tribunal within 28 days of the review decision