Residential Aged Care Application Form

We have updated the application form. This form is NO LONGER current. Please click the link below for the current form.

CLICK HERE FOR THE UPDATED APPLICATION FORM

Prior to completing this form you will require the following documents;

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 residential home are you applying for? *

Care required *

Permanent

Do you have an Aged Care Assessment? *

YesNo

Referral Code (if known)

ACAS Assessment

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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 *

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?

Contact details for this person are the same as the Medical and Wellbeing 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

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Please upload your Power of Attorney/Guardianship/VCAT Administrator

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

This field can include headings, formatted text, HTML code and more.

PROTECTING YOUR PRIVACY

Royal Freemasons is committedto 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

PERMANENT ENTRY

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 Human Services.The Department 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 the Department of Human Services, 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 below details are pure ly a tool for Royal Freemasons Ltd to use to provide a quote f or Permanent care. If you are awaiting confirmation on your Income and Assets Assessment from the Department, 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. The Department will issue you a statement outlining your contribution to the cost of your care and accommodation.

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 Amount *Money 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 Received *Per year

Deductible Amount *Amount 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 Received *A 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 Amount *Amount 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 amount *Per 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 Income *Annual rental income received before expenses are deducted.

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

Amount gifted *If 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

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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