This form must be completed by people seeking permanent residential aged care with Anglican Community Services, or their Power of Attorney or legal Guardian. 

We require the following information from you to ensure that we are not in breach of the provisions of the Aged Care Act 1997 in relation to accommodation payments and fees. To knowingly give false information in this form is an offence under the Act and will lead to the termination of your Resident Agreement. 

Please refer to the privacy section toward the end of the form, for information regarding the collection, use & disclosure of personal information. 

When completed, please select submit to return this form and attached documentation.

Please write your name exactly as shown on your ACAT Assessment Support Plan.

** failure to provide previously paid Means/ Income Tested Care Fee may result in overpaying the Means Tested Care Fee. If you don't have these amounts to hand, please contact your previous provider.

Items (a) and (b) below must be completed by all persons except those who choose not to disclose the net value of their assessable assets by selecting the checkbox below.

*Yes to any question, enter ‘$0’ against the value of your home in the asset list below
**No to all questions, enter the current market value of your home in the asset list below, up to the value of $206,039.20  

Please detail the value of all of your assets and, if a member of a couple, include all of your spouse/ partner’s assets and your joint assets:

Estimate Refund from Retirement Living  includes received or to be received.

Estimate Refund from an Aged Care facility refund of  an Accommodation Bond or Refundable Accommodation Deposit - includes received or to be received.

Total Financial Accounts (e.g. Bank accounts, term deposits, bonds, debentures, money on loan)

Current Market Value in Managed Investments (e.g. Investment trusts, personal investment plans, superannuation investments in accumulation phase)

Asset Value of Assessable Income Streams (e.g. Asset value of allocated pensions, annuities and superannuation pensions) – exclude Centrelink Age Pension

Shares (Australian stocks)

Foreign Assets (business or real-estate)

Real Estate and Business Interests

Private Trusts or Private Companies

Gifts/Deprivations (in excess of $30,000 over last 5 years)

Other Assets (e.g. motor vehicle, van, caravan, household furniture and personal effects).

Less: Total value of all debts including mortgages, loans, credit cards

Add: Estimate of the current market value of your home

Refer to (a) i above – amount capped at $206,039.20.

Please provide an estimate of your annual assessable income if above $31,140.20:

Annual Income Estimate (Government Income Support Payments)

Other income (eg foreign pension, interest from investments)

From time to time, the aged care home will need to contact a representative on your behalf about this application, your care or billing after you enter the home. Please provide contact details of your nominated representatives  below.

Anglicare requires nominated representatives for Clinical and Billing matters. These could be the same, or different people. Please ensure that these duties are covered by one or two of your support contacts.

In addition, if nominating a person who has the legal authority to make decisions for you, please advise the type of authority that they have, and upload their authority document to this application in the section titled Supporting documents.

What is a power of attorney?

Someone else (the attorney) acts on your behalf in matters of money and property.

What is guardianship?

In the event that you are unable to make decisions about your personal affairs, a guardian may be appointed by a State or Territory Government to act on your behalf. A guardian is generally appointed when, it is found that without an appointed guardian to manage your personal affairs, you pose a significant personal risk to yourself.

Include your billing contact here. If they are also your nominated contact for clinical matters, then please also check that field. Likewise, if they have additional authorities, then please capture those as well.

If your billing contact is not also your clinical contact, then please add the clinical contact here.

If you have another contact who is authorised to act on your behalf, please include them here and capture the relevant authorities.

Anglican Community Services (ACS) needs to collect aspects of your personal information prior to and during your admission into residential care. The primary purpose for the information is to assess, plan, deliver, and evaluate care. We may also use the information for staff training purposes and to manage, evaluate and improve services. Should ACS be unable to collect the personal information requested, it may be hampered in the provision of care and services.

Authorised representatives of the Department of Social Services, the Department of Health and Aged Care, and The Aged Care Quality & Safety Commission are provided with access to personal information for the secondary purpose of funding, Accreditation, and other functions under the Aged Care Act (1997).

ACS limits the collection of personal information to necessary information that is required to operate efficiently, effectively and in line with Statutory Requirements. Personal information that we collect about you includes:

• Name

• Date of birth

• Health and medial details

• Financial details

• Health insurance details
  

• Medicare number

• Government entitlements

• Emergency contact person

• Social needs details

• Religion/ cultural details
  

ACS has systems in place to protect your personal information from loss, alteration, improper use and inappropriate access and disclosure. We will comply with all applicable laws in relation to your personal information including the Privacy Act 1988, any applicable regulations & applicable regulatory guides.

If you have concerns about disclosing personal information to ACS, you should discuss these with the Facility Manager prior to your admission into the facility. Your decision not to disclose personal information may affect our ability to provide you with care and services deemed appropriate to your needs.

To view personal information kept about you by ACS, please speak with the Facility Manager. All requests to view personal information will be referred to ACS’s Privacy Officer. If we have reason to refuse you access to your information, we will explain why.

Our privacy policy can be located on our website: www.anglicare.org.au

Services Australia

If you are applying for Fully or Partially Supported accommodation, you must upload the following Services Australia documents.

or

or

If you are receiving a means tested income support payment, and own or part own a home, you can obtain the Assessment by completing a Residential Aged Care Property details form for Services Australia & DVA customers form (SA485). If you don’t own a home, you can request this Assessment by contacting Services Australia on 1800 227 475. If you don’t yet have a Sevices Australia assessment, you need to provide a Centrelink Income Statement as an interim measure.

Relevant legal authorities

If someone else has the legal power to make decisions on your behalf and/or is signing this application on your behalf, please upload the relevant authorities, such as Power of Attorney and Guardianship Papers

By checking this box, you declare that the information given in this form is true and complete, you give the undertaking that all information in relation to change to any Power of Attorney and/or appointment of Guardian or Financial Manager is provided and you have read Anglicare’s Collection, Use and Disclosure of Personal Information”

If this Application is being signed by an authorized signatory (e.g. Guardian, Attorney or Person Responsible), please insert name of signatory above and attach a copy of the relevant authorisation document.