SPM Customer Reimbursement Form

Please complete this form for reimbursement of your NDIS payments. Once submitted, this will be accepted by Specialised Plan Management as an authorised request to reimburse the expenditure on behalf of the stated participant from their NDIS plan.

Please note:

To enable fast processing of reimbursements, please upload your invoice showing a zero balance, or a copy of your payment receipt.
A bank statement or statutory declaration can also be used as proof of payment if no receipt can be obtained.
Please ensure all documentation is clear and easy to be read. Any documents that cannot be easily read and understood will cause a delay in the reimbursement processing timeframe, and may be rejected.

Date

Name of Person Completing This Form

Participant First Name

Participant Surname

Participant NDIS Number

Participant Date of Birth

Participant Email

Details of Expenditure

Reimbursement Amount

Upload Copy of Receipt for Payment

Upload Copy of Supplier Invoice or Quote

I can confirm that I have purchased services as per the attached receipt/invoice, which were approved items to be funded in my NDIS plan and seek reimbursement from my Plan Manager, Specialised Plan Management.

I confirm

Bank

Account Name

Account Number

BSB

Please tick if your bank details have changed recently.

My bank details have changed.