Part A Click to expand/hide

Are you applying for:

1. Applicant Details:

If applicable, please write your name exactly as shown on your Pensioner Concession Card

Title:

Last Name:

First Names(s):

Preferred Name:

Gender:

Date of Birth:

Marital Status:

Home Address:

Postcode:

If you have a Pensioner Concession Card, please write the card number here:

Please tick whether your Pensioner Concession Card is from:

2. Do you receive a full or part pension (or other income support payment) from Centrelink or the Department of Veterans’ Affairs?

What type of pension do you receive (eg., age, disability, service pension)?

3. Nominated representative

If you would like the aged care home to contact a representative on your behalf about this application or about your care after you enter the home, please provide their details below.
If you are nominating a person who has the legal authority to make decisions for you, please advise the type of authority that they have, such as Power of Attorney, and attach a photocopy of the authority to this application.

Details of your nominated representative:

Last Name:

First Names(s):

Home Address:

Postcode:

Contact numbers:

Email Address:

Relationship to you:

Type of authority (if applicable):

Photocopy of the authority to this application:

4. Responsibility for Paying Accounts and Receiving Correspondence

Do you wish to be responsible for receiving correspondence from the aged care home, including accounts, once you have accepted a place in the home?

Last Name:

First Names(s):

or, if applicable

Organisation:

Position in Organisation:

Postal Address:

Postcode:

Contact numbers:

Email Address:

Relationship to you:

If this person has the legal authority to make decisions for you, please advise the kind of authority that they have (eg Power of Attorney):

5. If you need an interpreter to help you with everyday English, please write the language you speak here

6. Please advise whether there are any cultural, religious or other organisations that you would like to remain in contact with once you have accepted a place in a residential aged care home

7. Please advise whether you have any cultural or religious requirements, such as specific dietary needs

If you are applying for a respite care place, go to Question 12 now.

8. Compensation Payments

Have you claimed and received a compensation award or settlement? If so, please indicate the type:

9. Extra Service Place

Would you like to find out about applying for an Extra Service Place, if your prospective aged care home can offer this to you?

10. Existing/Previous Resident of an Aged Care Home

Do you currently receive, or have you ever received, permanent care in a residential aged care home? If so, please complete the following details:

Name of current, or previous, residential aged care home:

Address of current, or previous, residential aged care home:

Postcode:

Date you accepted a place:

Date Departure (if applicable):

11. Spouse/Partner Information

Are you and your spouse/partner applying together for a place in an aged care home?

Does your spouse/partner already live in a residential aged care home?

If so, complete the following details:

Spouse/partner’s name:

Spouse/partner’s residential aged care home:

12. Important, please:

  • do not sign this form once you have completed it. First, make photocopies of the completed form, then sign each copy. Keep the original, as it may be required at the time you enter a residential aged care home;
  • attach a photocopy of your current Aged Care Assessment approval; and
  • attach a photocopy of the relevant authority, such as a Power of Attorney or Guardianship Papers, if someone else has the legal power to make decisions on your behalf.
  • If an authorised representative is signing this application on your behalf, please attach a copy of the documentation authorising the representative to act on your behalf, e.g. Power of Attorney.

Date:

Applicant's Signature:

IMPORTANT NOTE
This form is retained by the aged care home and is not passed to the Department of Social Services or any other Government agency. Therefore if you have nominated an authorised representative in this form, this relates only to dealings with the aged care home on your behalf.

Part B Click to expand/hide

Further information, needed at the time you enter care.

1. Health Care Card Details

If you have a Department of Veterans’ Affairs Gold Repatriation Health Care Card, please write the card number here:

Please write your Medicare details here:

The number that appears at the left of your name (e.g 1, 2):

If you have private health insurance, please write your details here:

If you have ambulance cover, please write your details here:

2. Medical and Health Professional Contacts

The following details are required to advise your residential aged care home of the contact information of the people who provide your health care:

Your General Practitioner:

Name:

Address:

Postcode:

Contact numbers:

Other Health Professional:

Name:

Field (e.g. audiologist, heart specialist):

Address:

Postcode:

Contact numbers:

Please advise the aged care home if there are other health professionals that you may need to consult while in the home.

3. Religious, Spiritual and Cultural Information

If there is someone you would like the residential aged care home to record as your religious, spiritual and/or cultural support person (such as a Minister) please complete the following details:

Name:

Name:

Position/Occupation:

Organisation:

Postal Address:

Postcode:

Contact numbers:

Email Address:

If an authorised representative is signing this form on your behalf, please ensure that a copy of the documentation authorising the representative to act on your behalf, e.g. Power of Attorney, has already been provided to the home.

Date:

Applicant's Signature: