Respite to Permanent 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.

If you need to stop part way through, select the "Save and Complete later" link at the bottom of the page, and we will send you a link to pick up where you left off. Please note that these drafts will be saved for 14 days at which time they will be cleared. 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 *

Resident contact details

Mobile Phone

Home phone

Email *

Documents preferred via *

emailmail

Street address *

City *

State *

Postcode *

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** *

While there did you opt in to the 2025 Aged Care Reforms? *

YesNo

If so on what date did you opt-in *

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

YesNo

Name of service provider *

Date entered support at home care *

Date departed support at home care

Total Means Tested Care Fee paid to previous provider** *

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

Were you approved, assigned or an active homecare package client on or before 12 September 2024? *

YesNo

NCCC paid against lifetime cap**

** Failure to provide previously paid Means/ Income Tested Care Fee or NCCC may result in overpaying the Means Tested Care Fee or NCCC. 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 $63,000.
You also understand that you will pay $127.45 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 $210,555.20.

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 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).

Total assets

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

Net assets

Member of couple *

YesNo

Adjust if a member of a couple

Add: Estimate of the current market value of your home

Refer to (a) i above – amount capped at $210,555.20

Net assets including home (if relevant - see a) above)

Please provide an estimate of your annual assessable income:

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.

What is a power of attorney?

Someone else (the attorney) acts on your behalf in matters of money and property. This person may access records where they relate to the attorney’s legal or financial responsibilities pertaining to you, such as your accounting or financial information, legally binding documents and bills. They are authorised to access your aged care records.

What is guardianship?

An enduring guardian can access records related to your health and lifestyle decisions, such as medical records, care plans, details of medical treatment, and details of lifestyle and accommodation. They are authorised to access your aged care records.

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.

What is a supporter?

A registered supporter helps you make and communicate your own decisions and need to be registered with the System Governor. A supporter does not make decision on your behalf unless they are a guardian, power of attorney, or hold similar authority.

Billing contact

Include your billing contact here. If they are also your nominated contact for clinical matters or emergency, 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. 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

NOTE: by nominating the above person, you consent to them receiving your health information and approving medication prescribed by a medical practitioner on the digital platform nominated by Anglicare.

Emergency

If not captured above, please provide the details of the person who should be contacted in case of emergency, and capture the relevant authorities.

First name *

Last name *

Address *

Street address *

City *

State *

Postcode *

Mobile phone

Home phone

Email *

Documents preferred via *

emailmail

Registered Supporter

If you have a Registered Supporter, then please provide the details of the relevant person 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

Is this person approved to receive information on your agreement? *

YesNo

Registration number

Privacy Collection Statement

Protecting your privacy

Anglican Community Services (‘Anglicare’) is committed to protecting your privacy and to ensuring we can provide you with the best possible care and services. We are bound by the Privacy Act 1988 (Cth) (the Privacy Act), the Australian Privacy Principles, the Health Records and Information Privacy Act 2002 (NSW), the Aged Care Act 2024 (Cth) (Aged Care Act) and Aged Care Rules 2025 (Cth) on and from commencement of the Act and Rules. Refer to our Privacy Policy which contains detailed information on how we protect your privacy; how to request access to your personal information; use and disclosure to third parties; and the complaint process. Our Privacy Policy is available on our website and on request.

Supporting documents

If you were assessed after 1/11/2025 you will need to provide this document.

Access approval letter

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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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Estimated Care Fee Letter - Resident

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Estimated Care Fee Letter - Partner

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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 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

General Power of Attorney

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Enduring Power of Attorney

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Guardianship order

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Enduring Guardian

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Financial Manager

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State Trustee

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Other legal authority - select type 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 any change to 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 *

Email Address *

Date *

If this Application is being signed by an authorised 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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