Application for Entry to Residential Aged Care

Transcription

1 Application for Entry to Residential Aged Care Aged Care Plus Centre you are applying for:... Applicant Name: The information you provide on this application form is information that Aged Care Plus requires to assess your needs and priority for entry into Residential Aged Care either for permanent or respite care. A separate application is required for each person applying for care. 2. Please note we cannot accept your application unless you have been assessed by an Aged Care Assessment Team (ACAT) and have been approved as a care recipient. 3. Prior to permanent entry into an Aged Care Plus Centre it is a requirement that you have arranged legal authority such as Enduring Power of Attorney (EPOA) and/or Enduring Guardian. 4. Please ensure you discuss your ongoing care with your current General Practitioner. Prior to admission into an Aged Care Plus Centre, it is a requirement to provide the name, address and contact details of your General Practitioner to ensure they are able to provide you with ongoing medical treatment within the Centre. On admission, you must bring a brief medical history, a list of your current medication and 3 days worth of medication supply (Webster pak or original packaging). 5. Important Note: A means assessment is undertaken by completing a Permanent Residential Aged Care Request for a Combined Assets and Income Assessment form and lodging it with the Department of Human Services or Department of Veteran s Affairs. This assessment determines both the Means Tested Care Fee (if any) you will pay as well as whether you qualify for Government assistance towards your accommodation costs. If you elect not to complete this form please note the maximum fees/payments will apply. If you accept a placement prior to being able to produce a determination letter you may be required to pay the full accommodation payment until you provide a copy of the letter. To be considered for a subsidised place you must lodge an application for a Combined Assets and Income Assessment and present the determination letter confirming the supported status when received. 6. Provide a copy of the following documents with this application form: A legible copy of your current Aged Care Assessment (ACAT/ACCR) or aged care referral code. A certified copy of any Enduring Power of Attorney and/or Guardianship documents. If Public Trustee is looking after your financial affairs, please provide a copy of Tribunal order. The Government determination letter from the Combined Assets and Income Assessment, if applicable. If transferring from another residential aged care centre where you were a permanent resident, please also provide the following documents: Copy of the residential agreement with previous aged care centre. Copy of latest fee statement and letter from the Department of Human Services. Care plan summary. For assistance with the completion of the Aged Care Plus application form, please do not hesitate to contact the Aged Care Plus Centre your are applying for directly. 1 of 6 agedcareplus.salvos.org.au

2 1. Placement Required: o Permanent o Respite 2. Aged Care Assessment Approval date:... Type of care approved: o Permanent o Respite Low o Respite High 3. Where did you hear about Aged Care Plus? Applicant Details (Person requiring Residential Care) Title:... Gender: o Male o Female Date of Birth:.../.../... Surname... Given Names:... Preferred Name... Marital Status: o Married o Defacto o Single o Widowed o Divorced o Separated Current residential address:... Telephone:... Mobile:... Country of Birth:... Nationality:... Preferred Language:... Religion (Optional):... Special requirement?... CURRENT LIVING ARRANGEMENTS: o At Home Alone o At Home with other(s) (specify relationship)... If at home, do you o own o rent o Department of Housing accommodation o Home of family member/other (specify relationship)... o Living in another Residential Aged Care Centre as a permanent resident 5. Pension details My Pensioner Concession Card is from: o Centrelink o Department of Veteran s Affairs o None Pension Concession Card number:... TYPE OF PENSION: o Aged pension o Disability pension o DVA pension o Overseas pension o Other, please indicate... PENSION: o Full pensioner o Part pensioner o Self funded retiree 6. Health Insurance and Medicare Details Medicare Card Number:... The number next to your name (eg 1)... Expiry Date:.../.../... If you have private health insurance, please provide details below Name of Fund:... Membership number and level of cover:... 2 of 6 agedcareplus.salvos.org.au

3 If you have private ambulance cover, please provide details below Name of Fund:... Membership number and level of cover: Nominated Representatives PRIMARY CONTACT If this person has authority to make decisions for you, please advise the type of authority. o EPOA o Guardianship Has the Enduring Power of Attorney been invoked? o Yes o No SECONDARY CONTACT If this person has authority to make decisions for you, please advise the type of authority. o EPOA o Guardianship Has the Enduring Power of Attorney been invoked? o Yes o No NEXT OF KIN If this is the person nominated as the primary contact, please write AS ABOVE 3 of 6 agedcareplus.salvos.org.au

4 8. Accounts and correspondence Please nominate who will be responsible for payment of accounts and receiving all correspondence, once you have accepted a place in the service o Primary Contact o Secondary Contact o Public Trustee (provide details) o Other (provide details) 9. Previous residential aged care admissions PERMANENT Have you been residing in an Aged Care Facility as a permanent resident previously? o Yes If yes, please provide the following details: o No Name of facility:......tel No:... Date of entry:.../.../... Date of discharge:.../.../... Have you paid an accommodation payment (eg Bond, RAD or DAP)? o Yes o No RESPITE Have you accessed respite in this financial year? o Yes - How many days?... o No 10. General Practitioner details Please provide details of a Doctor who will be able to provide ongoing care after you are admitted into an Aged Care Plus Centre. Full Name:... Medical Practice:... Contact details: Funeral arrangements Has a decision been made in respect to the preferred funeral service? o Yes o No Funeral Service Provider Name:... Telephone:... Are you interested in receiving information on Salvos Funerals in Sydney, Central Coast and Newcastle? o Yes o No NB. It is important for potential residents and/or families to discuss this topic and provide a response. Further end of life wishes and/or instructions will be sought following admission in conjunction with development of the Care Plan. Information is available onsite regarding local funeral arrangement options. 4 of 6 agedcareplus.salvos.org.au

5 12. Have you made a will? o Yes (please provide the details below) o No 13. Means Government Combined Assets and Income Assessment details PLEASE NOMINATE ONE OF THE 3 SECTIONS BELOW o SECTION 1 I have received a determination letter of means/assets from the Government, copy attached. o SECTION 2 I have lodged (or will lodge) the application for the Combined Assets and Income Assessment. I understand if I accept a placement prior to being able to produce a determination letter that I may be required to pay the full accommodation payment until I provide a copy of the determination letter. If lodged, please provide the date of lodgement:.../.../... o I have means (assessable assets and/or income) greater than the threshold specified by the Government and will be eligible to make a full Accommodation Payment. o I have means (assessable assets and/or income) below the threshold specified by the Government but do NOT have a letter from the Government confirming low means status. o SECTION 3 I choose not to lodge the application for the Combined Assets and Income Assessment. I understand I will pay the published price of the room I accept (RAD/DAP) and I may also be charged a maximum Means Tested Care Fee set by the Government. 14. Declaration Statement I declare that the answers to all of the questions given in this Application for Permanent Residential Care (whether in respect of myself, or on behalf of the applicant) are true and correct in every particular and is in no way false, inaccurate, incomplete, misleading or deceptive. I have (or will) provide The Salvation Army Aged Care Plus with all requested information and documentation for this application and for admission purposes (if the application proceeds). I understand and acknowledge I will be required to pay all fees, charges and payments as outlined in an agreement supplied in the event I am offered and accept a placement. I agree by completing this application to be wait listed for placement and that to allow the accurate determination of my financial status, I will provide further information or proof upon request. If I am signing on behalf of the applicant I confirm I have legal authority to act on their behalf. Signature:...Date:.../.../... Full name:... If signing on behalf of applicant, details of relationship status:... 5 of 6 agedcareplus.salvos.org.au

6 OFFICE USE ONLY ACAT Approval date.../.../... Approval: o Permanent o Respite Low o Respite High ACFI Score Forecast:... Admission approved by:... Pre Admission checklist o Information pack given o Tour booked.../.../... o Documents received o Fees explained and means determined (CS) o Agreement request sent (to CS) Post Admission Checklist o Residential Agreement given o Admission pack given o Resident entered into Epicor o Documents attached in Epicor o Resident file created Comments:... OFFICE USE ONLY Residential Agreement request 1. Agreement Required: o Permanent o Respite - how many days/weeks? Admission date.../.../... Pre-entry leave/holding room (if applicable).../.../ Room Number/Bed/Wing: Agreement Signatories on behalf of 4.1. Centre, 4.2. Resident (Resident or Representative) 4.1. Centre - Full name and Role:... Centre - Witness s full name: o Resident o Primary Person Responsible o Secondary Person Responsible o Public Trustee (provide detail below) o Other (provide detail below) If person signing on behalf of the resident has legal power (Enduring POA and/or Guardianship) please scan and send documents along with the application form. 5. Financial Status - Permanent only: o Supported (Fully or Partially) o Non Supported (RAD payer) Room price $...Negotiated price: $... 6 of 6 agedcareplus.salvos.org.au