Permanent Entry to Residential Aged Care Application Form

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 (document) 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 document, for information regarding the collection, use & disclosure of personal information.

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

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person_id893

Resident details

Aged care ID number - the letters AC followed by eight numbers *

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

First Name *

Last Name *

Middle Name

Preferred Name *

Date of Birth *

Gender *

MaleFemaleOther

Partner's name

Country of birth *

Nationality *

First language *

Interpreter required

YesNo

Aboriginal or Torres Strait Islander *

AboriginalTorres Strait IslanderBoth Aboriginal & Torres Strait IslanderNone of the Above

On the electoral roll *

YesNo

Religion *

Clergy

YesNo

Resident contact details

Mobile Phone

Home phone

Email *

Documents preferred via *

emailmail

Street address *

City *

State *

Postcode *

Government benefits

Medicare number *

Medicare position on card *

Medicare expiry date *

Pension status *

Full pension Part pensionSelf funded/no pension

Other pension type *

Centrelink / Pension number *

Pension card expiry date *

Veterans Affairs(DVA) card type *

DVA card number *

DVA card colour *

GoldWhiteOrange

Aged care services

Are you an existing/previous resident of an aged care home? *

YesNo

If yes, type of care received *

RespitePermanent

Name of service provider *

Respite days taken this financial year *

Date entered permanent care *

Date departed permanent care *

If permanent, Total Means/Income Tested Care Fee paid against lifetime cap** *

If permanent, Total Means/Income Tested Care Fee paid towards current year’s cap** *

Are you an existing/previous client of home care services? *

YesNo

Name of service provider *

Total Means/Income Tested Care Fee paid against lifetime cap** *

Total Means/Income Tested Care Fee paid towards current year’s cap** *

** 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.

Income and assets

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.

If you choose not to disclose your Income and Assets to Centrelink, tick this box. By ticking the box you also acknowledge that:

You are able to pay the maximum accommodation payment asked by Anglican Community Services and you will be left with assets of at least $59,500.
You also understand that you will pay $200 per day for the government Means Tested Fee until Anglicare receives advice from Services Australia.

a) Home ownership

Do you currently own or part-own a home? *

YesNo

Do you have a spouse, de facto partner or dependent child still living in the family home? Or

Yes*No**

Has a close family member been living in the family home for at least five years, and he/she is eligible for an income support payment? Or

Yes*No**

Has a carer been living in the family home for at least two years and he/she is eligible for an income support payment?

Yes*No**

*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.

Have you owned or part-owned a home in the past 2 years?

YesNo

b) Asset values

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 Aged Care facility’ (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).

Total of all above assets

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

Net value of assets (subtracts total debts from total assets)

Member of a couple *

YesNo

If a member of a couple, divide the above in two

Add: Estimate of the current market value of your home

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

Net assets

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)

Total income

Government Support - Payment Frequency

Other Income - Payment Frequency

Support contacts

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.

Billing contact

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.

First name

Last name

Address *

Street address *

City *

State *

Postcode *

Mobile phone

Home phone

Email *

Documents preferred via *

emailmail

Clinical contact

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

First name

Last name

Address *

Street address *

City *

State *

Postcode *

Mobile phone

Home phone

Email *

Documents preferred via *

emailmail

Other contact

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

First name

Last name

Address *

Street address *

City *

State *

Postcode *

Mobile phone

Home phone

Email *

Documents preferred via *

emailmail

Collection, Use and Disclosure of personal information

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

Supporting documents

Services Australia

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

Income & Means (Assets) Assessment

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Income Statement - Resident

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Income Statement - Partner

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And/or

Estimated Care Fee Letter - Resident

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Income Statement - Carer or Family

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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 SA on 1800 227 475. If you don’t yet have a Services 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

Power of attorney

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Power of attorney 2

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Power of attorney 3

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Guardianship 1

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Guardianship 2

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Guardianship 3

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Financial Manager

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State Trustee

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Other legal authority - describe below

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Signature & declaration

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”

I confirm that above information I have provided is true, complete and accurate. *

Name of applicant / authorised signatory *

Today's Date *

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.

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