1. Personal Information

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

1.1. Personal Prospective Residents Details

1.2. Marital Status

If YES, you will each need to complete your own Elderbloom Expression of Interest

1.3. Cultural Information

1.4 Your Current Location

1.5 Respite

1.6 Medical and Health Professional Contacts

The following details are required to advise your residential aged care home of the contact information of the people who provide your Health Care:

Your General Practitioner

Contact numbers

Other Health Professional

Contact numbers

1.7 Current COVID and Flu Vaccination Status

2: Pension and Medicare Information

Completing Sections 2 and 3 will assist us with determining your financial status so that we can provide you with draft fees and costs quote and answer any queries or concerns you may have.

2.1 Pension details

2.2 Medicare Details

If you have Private Health Insurance, please add your details here:

If you have Ambulance Cover, please add your details here

3: Nominated Representatives

Please provide details of the applicant’s nominated representative/s who Elderbloom can contact, regarding this application or about your care after you enter an Elderbloom residential facility.

Nominated Representative (Primary Contact)

Nominated Representative (Secondary Contact)

3.1 Responsibility for Paying Accounts and Receiving Correspondence:
(Must Be Enduring Power of Attorney Unless Nominated by Resident)

4: Assets and Income Information

Completing Sections 2 and 3 will assist us with determining your financial status so that we can provide you with draft fees and costs and answer any queries or concerns you may have.

4.1 Principal Home Information

ARE ANY OF THE ABOVE ELIGIBLE FOR AN ASSESSABLE PENSION/INCOME SUPPORT

(Note: Do not include a Carer Allowance)

4.2 Principal Home Financial Information

Estimation of Value of your principal home:

4.3 Assessable Assets and Income

If you have any combined assets with a spouse/partner/family please ONLY include the monetary value of your share

Other Assessable Assets

Assessable Income (per fortnight)

4.4 Assessment of your Income and Assets by Centrelink (prior to 01 July 2019)

4.5. Assessment of your Income and Assets by Centrelink (from 01 July 2019 onwards)

If you have not previously lodged a Form as of 01 July 2019 there are now different Centrelink processes for assessing your Income and Assets depending on your circumstances:

1. In Receipt of a Pension – Non-Home Owner

- No application required. For pre-assessment please call 1800 200 422

2. In Receipt of a Pension – Home Owner

- Complete and submit Residential Aged Care Property Details Form (SA485)

3. Self-Funded Retiree

- Complete and submit Residential Aged Care Calculation of Your Cost of Care Form (SA457)

Based on your circumstances please indicate if you have or are intending to submit:

4.6 Aged Care Assessment (ACAT)

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

Referral Code

If you do NOT have a copy of the ACAT please provide the referral code for PERMANENT RESIDENTIAL APPROVAL. This code starts with the number 1 – followed by 11 or 12 numbers. e.g. 1-2345678905

4.7 Current Health Status

Whilst the ACAT does provide health and medical information, if there have been changes to your health and wellbeing, then completing this section will further assist us in ensuring an offer of placement that reflects your care needs.

5: Time Frame for Residential Care Placement

5.1 Offer of Placement

If an offer is made for placement:
- we will contact you to view the available accommodation and request you attend the facility within 24 hours
- if placement is accepted admission will generally need to occur within 48-72 hours from time of offer.
Prior to any permanent placement, we must receive assessment of your Income and Assets by Centrelink (DVA) and your Aged Care Assessment or Aged Care Client Record.

Privacy of your personal information held by Elderbloom

The information collected on this form will only be:

• Used in connection with your application for residential care placement
• Be accessed by Elderbloom 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 to admission to a Elderbloom Residential Care Facility all documents will be securely disposed of.
• A complete Elderbloom Privacy Statement is available on request.

Application Checklist

To assist with the timely processing of your application please ensure that 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) which can also be referred to as an Aged Care Client Record (ACCR) or a Support Plan
OR
• Referral Code for Permanent Residential Code (refer to Section 4 of the Application)
• Copies of Power of Attorney and/or Guardianship approvals (if applicable)
• Copy of Centrelink Aged Care Fees Letter and Assets and Income Summary. (if received from Department of Human Services)
• A copy of vaccination record (if applicable).
• I understand the information provided and have completed all sections of this application.
• I have retained a copy of this application for my records.