Participant Reimbursement Claim Form

Our easy online tool to lodge your claim with EPSS

You can also print and fill out the form and email back to us at admin@essentialplan.com.au.

Participant Reimbursement Claim Form

Participant Details

Participant's Name(Required)

First Last

NDIS Number(Required)

Bank Details (If you have not yet provided this to us)

Account Name(Required)

BSB(Required)

Account Number(Required)

Support Provided and/or Items Purchased

Brief Description(Required)

Service Date(Required)

Support Category(Required)

Provider(Required)

Amount(Required)

Service Date

Support Category

Provider

Amount

Service Date

Support Category

Provider

Amount

Service Date

Support Category

Provider

Amount

TOTAL VALUE $ (AUD)(Required)

File(Required)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 50 MB.

Formal Declaration(Required)

I declare that the supports claimed have been received and paid for and that they meet the ‘reasonable and necessary’ legislation of NDIS, and

I understand that if audited and the National Disability Insurance Agency (NDIA) finds that the claim is not allowable under the plan, I may have to pay back the funds used.

Representative/Plan Nominee Name if Claimant is not the Participant(Required)

First Last

Claimant Email(Required)

Signature(Required)

Date Signed(Required)

Participant Reimbursement Claim Form

Our easy online tool to lodge your claim with EPSS

Participant Reimbursement Claim Form

Participant Details

Bank Details (If you have not yet provided this to us)

Support Provided and/or Items Purchased

Links

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