Residential Aged Care Application Form

Thank you for taking the time to complete our online application form for permanent care. Throughout this form you will be providing thefollowing information to complete the Application form, Privacy Collection, Activities, clothing Labels consent, direct debit and RoyalFreemasons Financial Statement. You will also be given the opportunity to uploaded relevant requested documents such as CovidVaccination Status and Power of Attorneys.This form will take approximately 15-20 minutes to complete. You can save this form and come back to it if you need to. To assist you to complete in this process we recommend that you have access to the following documents if applicable:

ACAS ( My Aged Care) Referral code
COVID-19 and Flu Vaccination Details
Pension/DVA Card
Medicare Card
Private Health Insurance details
Enduring Power of attorney
Latest bank Statements
Latest Council Property rates
Shares details
Prepaid/Funeral bond details

ACAS ( My Aged Care) Referral code

COVID-19 and Flu Vaccination Details

Pension/DVA Card

Medicare Card

Private Health Insurance details

Community GP details

Enduring Power(s) of Attorney details

Latest Bank Statements

Latest Council Property Rates

Shares details

Prepaid/Funeral Bond details

Application Form

Which site are you applying for? *

Care required *

PermanentRespite

Do you have an Aged Care Assessment? *

YesNo

Referral Code (if known)

ACAS Assessment

Browse

Please upload your ACAS assessment or any other relevant documents

Where is the applicant coming from? *

Name of previous Aged Care Home *

Address

Date of admission *

Date of discharge *

Have you paid a RAD?

YesNo

RAD Value? *

Resident Details

Title *

First name *

Last name *

Email address

Home Phone Number *

Mobile Number

Address *

Date of Birth *

Gender *

Nationality *

Religion

Marital Status *

Do you identify as Aboriginal or Torres Strait Islander? *

YesNo

Have you received any COVID-19 vaccinations? *Note: You will need to provide evidence of vaccination prior to admission.

Covid-19 vaccination

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Please upload your Covid-19 vaccination certificate

Date of last dose *

Type of vaccine received *eg Pfizer, AstraZeneca

Pension & Benefit Details

I hold an Australian Pension Concession Card

Australian Pension Number *

Pension Status *

FullPart

Pension Expiry Date *

I have a DVA pension

DVA pension number *

Pension Type *

GoldWhiteOrange

Pension Expiry Date *

I am an NDIS Participant

NDIS number *

NDIS provider

I have a Medicare card *

Name on card *

Medicare number *

Expiry Date *

Card reference number *

Do you have private health insurance?

Name of fund *

Member number

Do you have Ambulance cover?

Member number

Contact Details - Medical and Health Professional

Practice Name *

GP First Name *

GP Last Name *

Practice Address *

Contact Number

Contact Details - Resident representative

Title *

First Name *

Last Name *

Home Address *

Email Address *

Phone Number *

Mobile Number

Relationship to Resident *eg Daughter, Son, Wife, Cousin, Social Worker

Authority Type

Power of Attorney - MedicalPower of Attorney - FinancialGuardianshipVCAT Administrator

Contact Details - Medical and Wellbeing representative

Contact details for this person are the same as the Resident Representative (As above).

Title *

First Name *

Last Name *

Organisation

Address *

Email Address *

Phone Number *

Mobile Number

Relationship to Resident *

If other, please state relationship

Authority type

Power of Attorney - MedicalPower of Attorney - FinancialGuardianshipVCAT Administrator

Power of Attorney

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Please upload your Power of Attorney/Guardianship/VCAT Administrator

Contact Details - Legal and Financial representative

Contact details for this person are the same as the Resident Representative?

Title *

First Name *

Last Name *

Organisation

Address *

Email Address *

Phone Number *

Mobile Number

Relationship to Resident *

If other, please state relationship

Authority type

Power of Attorney - MedicalPower of Attorney - FinancialGuardianshipVCAT Administrator

Power of Attorney

Browse

Please upload your Power of Attorney/Guardianship/VCAT Administrator

Secondary contact

Title *

First Name *

Last Name *

Organisation

Address *

Email Address *

Phone Number *

Mobile Number

Relationship to Resident *

If other, please state relationship

Current Services

Do you recieve in-home or community care?

Provider Name *

Date service commenced *

Correspondence

Where would you like your resident agreement to be sent? *

ResidentResidents RepresentativeLegal and Financial RepresentativeMedical and Wellbeing Representative

How would you like them sent? *

EmailPostIn person

Where would you like your financial correspondence to be sent? *

ResidentResidents RepresentativeLegal and Financial RepresentativeMedical and Wellbeing Representative

How would you like them sent? *

EmailPostIn person

Privacy Collection Statement

PROTECTING YOUR PRIVACY

Royal Freemasons 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 Act1988 (Cth) (the Privacy Act) and the Australian Privacy Principles. This Privacy Collection Statement should be read in conjunction with our Privacy Policy which contains detailed information on how we protect your privacy, including the way in which we may collect, use and disclose your information. A copy of our Privacy Policy is available on our website or at our facility. We will provide a copy of our Privacy Policy to you when you move into our facility or before we start providing services to you.

COLLECTION OF INFORMATION

We collect personal information about individuals directly from the individual or their legal representative. We will only collect information for a purpose that relates directly to our functions and activities as an aged care provider. We understand that you may not want to provide information to us. The information we request of you is relevant to providing you with the care and services you need. If you choose not to provide us with some or all of the information we request, we may not be able to provide youwith the care and services you require. For more detailed information, please refer to our Privacy Policy

USE AND DISCLOSURE

We will use and disclose your personal information only for the purpose for which it was collected or for any other purpose that is otherwise directly related to our functions or activities as an aged care provider or otherwise permitted at law. Please refer to our Privacy Policy for more detailed information.

ACCESS AND CORRECTION OF INFORMATION

Our Privacy Policy also contains detailed information on how you may access the personal information we hold about you and how you can seek to have your personal information corrected.

CONSENT

We require your consent to collect, use and disclose your personal health information so that we are able to provide you with care and services you require. By signing this document, you are giving us consent to collect, use and disclose your personal information (including health information) in accordance with this document and our Privacy Policy. If we intend to use your health information for any other purpose, we will seek further consent from you.

OVERSEAS RECIPIENTS

We will not disclose your information to overseas recipients. If we do, we will take all steps that are reasonable in the circumstances to ensure that the overseas recipient does not breach the Australian Privacy Principles.

MAKING A COMPLAINT

If you wish to make a complaintabout the way we have managedyour personal information you may make that complaint verbally or in writing by setting out the details of your complaint to any of the following:

1. The Privacy Officer on Phone:1300 17 69 25 or via email marked Privacy Request to info@royalfreemasons.org.au

2. Aged Care Quality and Safety Commissioner Online: At www.agedcarequality.gov.au By phone on 1800 951 822.

3. Office of Australian Information Commissioner

HOW TO CONTACT US

If you have any questions in relation to privacy or how we manage your personal information, please contact us on 1300 17 69 25. Alternatively, you can email: info@royalfreemasons.org.au

I acknowledge that:

I have read the information above and understand the reasons for why my information must be collected;

I understand that I am not obliged to provide any information requested of me, but failure to do so may prevent me from receiving care and services that I require; *

I am aware of my rights to access the information collected about me, as outlined in the Privacy Policy; *

I am aware of my right to request access to my information; *

I am aware of my right to amend my information if I believe is incorrect; *

I am aware of the complaints procedure set out above; and

I understand that if my information is to be used for any other purpose other than that set out above, my further consent will be obtained *

Financial Statement Form

The purpose of this Financial Statement is to determine your affordability for your care and accommodation as a permanent resident. If you are applying for respite Care you are NOT required to complete this Financial Statement.

INCOME AND ASSETS STATEMENT

You must complete this Financial Statement, if you do not have your Income and Assets Statement from Centrelink or Department of Veteran Affairs to assist us determine your fees and charges as a permanent resident. You are required to lodge your Centrelink Income and Assets Assessment with the Department of Health and Human Services (DHHS). They will make an assessment on your ability to contribute to the cost of your care and accommodation. Should you not lodge your Income and Assets Assessment with DHHS, we will need to charge you the maximum amount permitted under the Aged Care Act 1997 for your Care and Accommodation which is set out in the Schedule of Fees and Charges from the Department of Health. The information you provide in this form will be used by Royal Freemasons Ltd to provide you with a quote for permanent care. If you are awaiting confirmation on your Income and Assets Assessment from DHHS, we can provide you with an estimate of the maximum amount we can charge you for your care and accommodation. We cannot advise you of the exact amount you will be required to pay until the Department has processed your Income and Assets Assessment. DHHS will issue you a statement outlining your contribution to the cost of your care and accommodation.

GUARANTOR

We ask some residents to provide a guarantee. A guarantee is a promise by a third party (such as a family member) to pay all of your fees and charges in the event you cannot do so. We do not require a guarantee from a resident who is fully supported (i.e. a person who has been assessed by DHHS or the Department of Veteran Affairs as not being able to contribute to the costs of their care or accommodation) or for those residents whose affairs are being managed by the Public Trustee.Should you elect to pay more than 50% of the published price for your room as a lump sum, we will no longer rely on your guarantor.

DECLARATION

Declare the information provided on this Financial Statement is true and correct. Signature required.

Family Home

Spouse/Partner Full Name *When completing this form you must combine both income and assets

Spouse/Partner Date of birth *

Does the Resident own their own home? *

YesNo

Will anyone remain living in the family home? *

The home will remain emptyLiving with partner or dependent childLiving with carer, eligible for income support payments who has resided for over 2 years Living with a close relative, eligible for income support payment who has resided for over 5 yearsNone of the above

Family home net market value? *Value of property after costs and expenses are deducted.

Does the Resident intend to keep the home? *

YesNo

Does the Resident intent to rent the family home? *

YesNo

Gross Rental Income *Rental income received before expenses are deducted.

Rental Income Frequency *

Income

Do you receive an Aged Care Pension?

Do you receive a Blind Pension?

Do you receive a Veteran's Affairs War Widow Pension + Income Support Suuplement?

Do you receive an Account Based Pension?

Account based pension Asset AmountMoney that has been contributed into a superannuation fund by you while you have been working, a regular income stream is payable to you. You can take the money as a regular payment or a lump sum. The deductible amount is the amount of income that is a return of capital versus income.

Total Income ReceivedPer year

Deductible AmountAmount which is not assessed as income, and can be sourced from your Policy Document or Centrelink Investment schedule.

Do you receive an Employment income?

Annual Income (before tax)

Do you receive an Overseas Pension?

Annual Income (before tax)

Do you receive a Superannuation Pension?

Gross Income ReceivedA superannuation pension is also known as a superannuation income stream, and is sometimes called a retirement income stream. The technical term for a superannuation pension is a 'complying pension' (that is complying with the superannuation rules). The deductible amount is the amount of income that is a return of capital versus income. There is no ability to take a lump sum amount and payments typically cease upon death unless the income stream has been transferred to a surviving spouse.

Deductible AmountAmount which is not assessed as income, and can be sourced from your Policy Document or Centrelink Investment schedule.

Frequency

Do you receive any other income?

Other Income amountPer year

Assets

Home Contents *Please estimate how much you would receive if you sold everything at a garage sale.

Motor Vehicles, Boats, Caravans or Trailers

Special Collections, Art or Antiques

Bank Account *Please combine all accounts

Cash not kept in financial institutions

Funeral BondAn investment policy allocated to your funeral expenses

Insurance or Government Bonds

Life insurance that can be encashed

Managed Fund

Prepaid FuneralA funeral prepaid at a Funeral Home.

Shares, options, rights, convertible notes in listed or unlisted companies

Do you own investment properties?

Market Value

Gross Rental IncomeAnnual rental income received before expenses are deducted.

Have you gifted away any assets in the last 5 years?

Amount giftedIf you have gifted away funds on more than one occasion, please contact your Customer Relocations Consultant

Date gifted Month and Year

Do you currently have any debt owing?Credit cards, personal loans, money owing, mortgages or any other debt that you are going to repay.

Activities Consent Form

1. Photography
I give permission for images to be taken during activities conducted by the facility, to be displayed or used in publications, newsletters and reports by Royal Freemasons Ltd.

2. Personal Information
I give permission for personal information such as birthdays, anniversaries and other celebrations specified on the Personal History/Life Profile form to be announced or celebrated with other residents and staff. I give permission for personal information such as birthdays, anniversaries and other celebrations specified on the Personal History/Life Profile form to be published newsletters and other publications by Royal Freemasons Ltd or displayed in allocated rooms. I give permission for my own/relative/resident’s name to be displayed on the room door to as assist with easy identification.

3. Activities of Risk
I give permission for my relative/resident to participate in outing and special activities. I accept that there may be potential for risks associated with participation in activities, particularly outside the perimeters of Royal Freemasons Ltd. I acknowledge that staff involved will seek to provide a safe and comfortable environment for activities, in consideration of any medical conditions and observance of relevant emergency procedures in the event of any incident or medical emergency

4. Freedom of Choice
I acknowledge the right to refuse participation in activities provided by the facility. I understand that activity preferences will be respected. I understand that any therapeutic activities offered will be provided to address specifically assessed needs to improve or minimise loss of function and that refusal to undertake these activities may result in a deterioration in functional independence. I understand the right to receive alternative or complimentary therapies.

Was the activities consent form completed in consultation with the resident? *

YesNo

Clothing Labels Form

To support privacy, dignity and in an effort to minimise the likelihood of personal clothing being lost or misplaced, residents are encouraged to label all clothing items with clothes labels. These can be purchased and affixed by Royal Freemasons Ltd. The cost of labels purchased will appear on your first monthly accommodation invoice

I wish to purchase

20 labels total cost $840 labels total cost $1660 labels total cost $24

Direct Debit Request

Resident's given names *

Resident's surname ("You") *

“You” request and authorise Royal Freemasons Ltd (Direct Entry ID 142034) to arrange a debit to your nominated account to pay any amount Royal Freemasons Ltd has deemed payable by you.

This debit or charge will be arranged by Royal Freemasons Ltd financial institution and made through the Bulk Electronic Clearing System Framework (BECS) from your nominated account and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

Your account to be debited

Name/s on account *

Financial institution name *

BSB number (must be 6 Digits) *

Account number *

Confirmation

By signing and/or providing us with a valid instruction in respect to Your Direct Debit Request, you confirm that:

you are authorised to operate the nominated account; and
you have understood and agreed to the terms and conditions set out in this request and in Your Direct Debit Request Service Agreement.

Your signature

Signed in accordance with the account authority on your account:

Name *

Phone *

Email *

Address *

Street address *

City *

State *

Postcode *

Signature *

Draw signature|Type signatureClear

Date *

There is a second account signatory

Signed in accordance with the account authority on your account

Name *

Phone *

Address *

Street address *

City *

State *

Postcode *

Signature *

Draw signature|Type signatureClear

Date *

This is Your Direct Debit Service Agreement with Royal Freemasons Ltd ABN 52 082 106 821 (Direct Entry ID 142034). It explains what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as Your Direct Debit provider.Please keep this agreement for future reference. It forms part of the terms and conditions of Your Direct Debit Request (DDR) and should be read in conjunction with Your DDR authorisation.

Definitions

account means the account held at your financial institution from which we are authorised to arrange for funds to be debited.

agreement means this Direct Debit Request Service Agreement between you and us.

banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia.

debit day means the day that payment by you to us is due.

debit payment means a particular transaction where a debit is made.

Direct Debit Request means the written, verbal or online request between us and you to debit funds from your account.

us or we means Royal Freemasons Ltd, (the Debit User) you have authorised by requesting a Direct Debit Request.

you means the customer who has authorised the Direct Debit Request.

your financial institution means the financial institution at which you hold the account you have authorised us to debit.

1. Debiting your account

By submitting a Direct Debit Request you have authorised us to arrange for funds to be debited from your account. The Direct Debit Request and this agreement set out the terms of the arrangement between us and you.
We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request. or We will only arrange for funds to be debited from your account if we have sent to the address nominated by you in the Direct Debit Request, a billing advice which specifies the amount payable by you to us and when it is due.
If the debit day falls on a day that is not a banking day, we may direct your financial institution to debit your account on the following banking day. If you are unsure about which day your account has or will be debited you should ask your financial institution.

2. Amendments by us

We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice sent to the preferred email or address you have given us in the Direct Debit Request.

3 How to cancel or change direct debits

You can:

Cancel or suspend the Direct Debit Request; or
change, stop or defer an individual debit payment, at any time by giving us at least 30 days notice

by emailing us at ar@royalfreemasons.org.au,

or by writing to:Royal Freemasons,45 Moubray Street, Melbourne VIC 3004

or by telephoning us on 1300 176 925 during business hours;

or arranging it through your own financial institution, which must act promptly on your instructions.

4. Your obligations

It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request.
If there are insufficient clear funds in your account to meet a debit payment: a. you may be charged a fee and/or interest by your financial institution; b. we may charge you reasonable costs incurred by us on account of there being insufficient funds; and c. you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment
You should check your account statement to verify that the amounts debited from your account are correct.

5. Dispute

If you believe that there has been an error in debiting your account, you should notify us directly on ar@royalfreemasons.org.au or 1300 176 925. Alternatively, you can contact your financial institution for assistance.
If we conclude, as a result of our investigations, that your account has been incorrectly debited, we will respond to your query by arranging within a reasonable period for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted.
If we conclude, as a result of our investigations, that your account has not been incorrectly debited, we will respond to your query by providing you with reasons and any evidence for this finding in writing.

6. Accounts

You should check:

with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions.
your account details which you have provided to us are correct by checking them against a recent account statement; and
with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request

7. Confidentiality

We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.
We will only disclose information that we have about you: a. to the extent specifically required by law; or b.for the purposes of this agreement (including disclosing information in connection with any query or claim).

8. Contacting each other

If you wish to notify us in writing about anything relating to this agreement, you should write to Royal Freemasons Ltd, 45 Moubray Street, Melbourne VIC 3004.
We will notify you by sending a notice to the preferred address or email you have given us in the Direct Debit Request. Any notice will be deemed to have been received on the second banking day after sending.

Signature Page

Resident Name *

Print name *

Signature *

Draw signature|Type signatureClear

Date *

Power of Attorney

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If you have not yet done so, please upload your Power of Attorney/Guardianship/VCAT Administrator

I am happy to receive communication and marketing more information from Royal Freemasons.

Note: Your privacy is important to us. We will not share your details without your consent – refer to our privacy policy for more information.

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