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Application for Permanent Residential Aged Care

Thank you for your interest in considering placement at our Residential Care Facility.

To assist us with planning your care needs and accommodation requirements please complete ALL sections of this form.

1. Personal Information

Completing this section will assist us with getting to know more about you and your representatives.

1.1 Applicant Details:

First Name(s):

Preferred Name:

Home Address:

Suburb:

State:

Post Code:

Home Phone:

Mobile Phone:

Date of Birth:

Gender:
MaleFemaleOther
If Other, please specify:

1.2 Marital Status:

Are you and your spouse/ partner applying jointly for this facility ?
YesNoN/A

If YES, you will each need to complete a separate Application Form,

1.3 Cultural Information:

Are you an Aboriginal or Torres Strait Islander?
YesNo

Nationality:

Country of Birth:

Language/s Spoken:

Interpreter required:
YesNo

1.4 Nominated Representatives:

Please provide details of your nominated representative/s who we can contact regarding this application and about your care after entering our Facility.

Nominated Representative (Primary Contact)

Name:

Relationship:

Home Address:

Suburb:

State:

Post Code:

Daytime Phone:

Mobile Phone:

Email:

Type of Authority:
NilEnduring Power of GuardianshipEnduring Power of AttorneyOther
If Other, please specify:

Nominated Representative (Secondary Contact)

Name:

Relationship:

Home Address:

Suburb:

State:

Post Code:

Daytime Phone:

Mobile Phone:

Email:

Type of Authority:
NilEnduring Power of GuardianshipEnduring Power of AttorneyOther
If Other, please specify:

1.5 Responsibility for Paying Accounts and Receiving Correspondence:

Do you wish to be responsible for receiving correspondence from this organisation, including accounts, once you have accepted accommodation?

Yes, I would like to receive correspondenceNo, I would like my nominated representative in Section 1.4 to receive correspondenceNo, I would like to nominate someone else

If you nominate someone else, please provide their details below:

Name:

Organisation (if applicable):

Postal Address:

Post Code:

Daytime Phone:

Mobile Phone:

Email:

Type of Legal Authority (if applicable):

1.6 Your Current Location:

Home (Address):

Other Residence (e.g. with family) (Address):

Hospital (please specify):

Transitional Care (TCP) (please specify):

Date of admission to Transitional Care:

Other Residential Care Facility (please specify):

Date of admission to other Residential Care Facility:

2. Pension and Medicare Information

2.1 Pension Details:

Pension / DVA Card No:

Expiry Date:

If DVA, please specify Card colour:

Non-Australian Pension:
YesNo

Type of Pension:

Country:

Self-Funded Retiree:
YesNo

Type of Pension:

2.2 Medicare Details:

Medicare Card:
YesNo

Medicare Card No:

Expiry Date:

Medicare Reference No:

(the number that appears at the left of your name)

If you have Private Health Insurance, please write the details below:

Name of Fund:

Membership No:

Level of Cover:

If you have Ambulance Cover, please write the details here:

Name of Fund:

Membership No:

3. Your Health Information

3.1 Medical and Health Professional Contacts:

The following details are required to advise our facility of the contact information of the people who provide your health care:

Your General Practitioner:

Name:

Address:

Post Code:

Daytime Phone:

Mobile Phone:

Email:

Other Health Professional/s:(Attach a separate sheet if more than one)

Name:

Field (e.g. Cardiologist, Audiologist):

Address:

Post Code:

Daytime Phone:

Mobile Phone:

Email:

You can advise us post admission if there are any other health professionals that you may need to consult whilst residing with us.

3.2 The Aged Care Assessment:

An ACAT Assessment can also be called an Aged Care Client Record (ACCR) or a Support Plan.

Have you had an ACAT Assessment?YesNo

Date of ACAT Assessment:

If YES, do you have a copy of the ACAT Assessment?YesNo

If YES, please include a copy with your application.

If NO, please provide the referral code for Residential Permanent:

The referral code is a unique number listed on the Support Plan.

3.3 Current Health Status:

If there have been any changes to your health and wellbeing since your ACAT assessment, then completing this section will further assist us in assessing your care needs.

Have you had any new medical diagnosis or changes to your care needs since your ACAT assessment?YesNo

If YES, please record any new medical diagnoses/ changes in care need:

4. Timeframe and Type of Residential Care Placement

Are you applying for:

Residential Permanent Care

Please indicate the likely timeframe you are seeking for placement:

Urgent / as soon as possibleWithin Three monthsThree - Six monthsSix months and over

Please Note: If your circumstances change, please contact Dale Cottages Inc on (08) 9497 3200 to update your preferred timeframe for placement.

5. Assessment of your Income and Assets by Services Australia

Have you lodged an Income and Assets Assessment Form with Centrelink/DVA or contacted Centrelink/DVA for a Residential Care Fee Letter?

YesNo — please see the note below

If YES, have you received the Fee Letter from Services Australia?

Yes — please include a copy with your application.No — please provide a copy when you receive it.

Please Note: If the Income and Asset Assessment form hasn’t been submitted to Centrelink/DVA or if it’s been submitted and you have yet to receive the ‘Residential Care Fee’ letter, we will charge and direct debit the applicable Daily Accommodation Payment until we receive notification from Services Australia on the outcome of the assessment. Once this information is received, your fees will be recalculated and backdated to the date of entry and a credit, if applicable, will be applied to the fee charged or refunded back to your nominated bank account.

6. Declaration

Full Name of Person Making the Declaration:

Relationship to the Applicant (if applicable):

sincerely declare that all of the information in this application is true to the best of my knowledge. It is in no way false, inaccurate or misleading, or intended to be false, inaccurate or misleading.

Signature:

Date:

Privacy of your personal information held by Dale Cottages Inc:

Used in connection with your application for residential care.
Accessed by Dale Cottages staff to the extent necessary to perform their duties and will not be released to a third party without your consent.

if you do not proceed with admission to our Residential Care Facility, all documents will be securely disposed of.

you have any queries regarding any of the sections on this application please do not hesitate to contact us on:

Phone: (08) 9497 3200 (MON-FRI 10AM - 3PM)

Email: cp@dalecottages.org

7. Application Checklist

To assist with the timely processing of your application, please ensure all sections are completed to the best of your ability and that you have provided the following documents/information with this application:

A copy of your Aged Care Assessment (ACAT) / Aged Care Client Record (ACCR) / Support plan or provide the Referral code for Permanent Residential Care.
Immunisation record of any Influenza and Covid-19 vaccinations (Medicare copy required)
Copies of any Power of Attorney and/or Guardianship or Administration approvals (if applicable)
Copy of the Aged Care Fees letter and Assets and Income Summary from Services Australia (if received)

Please ensure that you understand the information provided and have completed all sections of this application.
We recommended that you retain a copy of this application for your records.

Application for Permanent Residential Aged Care

1. Personal Information

2. Pension and Medicare Information

3. Your Health Information

4. Timeframe and Type of Residential Care Placement

5. Assessment of your Income and Assets by Services Australia

6. Declaration

7. Application Checklist

Thank you for completing this application for admission to our Residential Care Facility

Once received, we will contact you or your representative should we require any further information.

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