Respite 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 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.

lead_id391

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 pensionPart 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 *

Income

If you receive a full or part pension and choose not to provide Anglicare with an Income Statement or Estimated Fee letter from Services Australia, tick this box. By ticking this box, I understand that I will be required to pay the full Additional Services Fee.

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

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.

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

Landline

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 SA 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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