Customer Reimbursement Form

Reimburse an NDIS expense

Please complete this form for reimbursement of your NDIS payments. Once submitted, this will be accepted by Specialised Plan Services 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.

"*" indicates required fields

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 of payment or invoice*

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Your bank details

Bank Name*

Account Name*

Account Number*

BSB*

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