Admission Application - Infinite Care · 2020. 6. 15. · o Partner deceased o Partner separated o...

INFINITE CARE

Admission Application

Innovative aged care... where people matter

infin8care.com.au | 1800 463 468

1800 463 468 | [email protected] infin8care.com.au

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Deciding on the right residential care service can be a stressful decision for all in the family. At Infinite Care we understand the emotional and complex decision process that residential aged care poses for families. We are here to help take some of that stress away and can empathise and help you feel comfortable in the choices you are making for yourself or a loved one. We also understand that it’s going to be your home and we can tailor the experience so you do feel right at home.

Our culture will always be family.

You matter to us. Your family matter to us. Your life choices matter to us. We care about YOU!

We look forward to you joining the extended Infinite family.

APPLICATION FORM

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Personal Details Date

Title Gender Male / Female (circle)

Given Names

Preferred Name Surname

D.O.B Birthplace

Telephone Mobile

Email

Current residential address

State Postcode

Languages spoken Religion

Type of Care Required

o Permanent care o Respite care (If respite, please state length of stay required)

Present Living Arrangements

o At home – live alone

o At home – live with spouse

If at home, is this owned by you / rented (circle)

o At home with another person (not spouse) Relationship:

o Home of family member / other Relationship:

o Other Residential Aged Care Facility Name of facility:

o Interim / transition care

o Hospital

Indigenous status o Unknown o Aboriginal o Torres Strait Islander

o Neither o Both Aboriginal and Torres Strait Islander

APPLICATION FORM


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Nominated Representative

Full Name

Relationship

Address

State Postcode

Telephone Email

Second Nominated Representative

Full Name

Relationship

Address

State Postcode

Telephone Email

o Emergency contact o Executor to Will o Medical (POA)

o Financial (billing address) o Enduring Power of Attorney (EPoA) o Next of Kin

Relationship (If you have a spouse or partner, please supply their full name and address below)

o Single o Married o Widowed o Partner

o Partner deceased o Partner separated o Partner divorced

Name

Address

State Postcode

o Emergency contact o Executor to Will o Medical (POA)

o Financial (billing address) o Enduring Power of Attorney (EPoA) o Next of Kin

APPLICATION FORM

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Emergency Contact

An emergency is a significant change in your medical condition.

May we contact this person at any hour of the day or night? Yes / No (circle)

If no, between which hours can this person be contacted? _____am / _____pm

Please indicate if you have any of the following in place and provide a copy with your application. (circle below)

Power of Attorney Yes / No

Enduring Guardian Yes / No

Guardianship Order Yes / No

Public Trustee Order Yes / No

Advanced Care Directive Yes / No

Would you like to receive marketing updates from Infinite Care? Yes / No (circle)

Accounts and Correspondence

I nominate the following person to receive all correspondence:

o Myself (person requiring residential care)

o Nominated representative (from previous page)

o Other

Full name

Telephone

Email (for financial statements)

How Did You Hear About Us?

o Respite care o Newspaper o Infinite website o Hospital

o Word of mouth o GP o Radio o Family

o My Aged Care o Letterbox drop o Other o Other aged care website

APPLICATION FORM


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Timeframe for Admission

o Immediate o 3 months o 6 months o 12 months

Preferred Accommodation Type

o Single room o Couple accommodation

o Single room with ensuite o Dementia and Memory Support

Proposed date of admission _____/_____/_____

Pension Status

What type of pension do you receive?

o Full Pension o Part Pension o No Pension

Have you used any of the following services in the current financial year (1 July to 30 June)? (circle below)

Residential Respite Yes / No

Permanent Residential Aged Care Yes / No

In Home Respite Care Yes / No

Home Care Package Yes / No

If any, please specify the service providers and dates for the services used above.

Name of Service Provider

Type of Service

Dates

Are you seeking to transfer from another Residential Aged Care Service? Yes / No (circle)

Name of Aged Care Facility

What date did you enter aged care? _____/_____/_____

APPLICATION FORM

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ACAT Assessment

Before you can apply for either permanent or respite care, you must have a current assessment form a local Aged Care Assessment Team (ACAT) that states you are eligible to receive residential care. This assessment can also be called an Aged Care Client Record (ACCR) or a Support Plan.

Have you had a formal assessment by the Aged Care Assessment Team? Yes / No (circle)

My Aged Care Referral Code 1-

(Please attach a copy of your My Aged Care Support Plan)

Health and Ambulance Cover

If you have private health insurance, please provide details below:

Name of fund

Membership number

Level of cover

If you have ambulance cover, please write the details below (if applicable):

Name of fund

Membership number

Expiry _____/_____/_____

Medical Information Please attach medical history from doctor’s surgery

Doctor’s name

Telephone number

Doctor’s surgery name

Doctor’s surgery address

APPLICATION FORM


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General Information

Medicare number

Medicare reference number Expiry _____/_____/_____

Pension number Expiry _____/_____/_____

Veteran affairs number Expiry _____/_____/_____(gold / white)

Diabetic assoc. number Expiry _____/_____/_____

Legal and Financial Details

Does the Applicant have an Enduring Power of Attorney? (EPoA) Yes / No (circle)

Is the EPoA currently active?

o Yes – due to incapacity (medical practitioners letter attached)

o Yes – other reason (ie immediate power)

o No – does the applicant have the ability to understand and make complex financial decisions? Yes / No (circle)

APPLICATION FORM

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Attorney Details

Title Surname

Given Names

Address

State Postcode

Telephone Business Hours

After Hours

Mobile

Email

If you are awaiting a QCAT, NCAT or SACAT hearing, please specify the following and provide a copy of the order:

Hearing Date

Case Manager Name

Reference Number

Do you have an Advanced Health Directive? Yes / No (circle)

(If yes, please attach a copy)

Has a decision been made with regards to a preferred funeral service provider? Yes / No (circle)

If yes, please provide details

Name

Telephone

APPLICATION FORM


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Financial

Have you made a will? Yes / No (circle)

If yes, please provide the details of the Executor and person/organisation holding the will.

Title Surname

Given Names

Address

State Postcode


After Hours

Mobile

Email

If you have an Aged Care Fee advice please attach a copy of the advice to this application.

Title Surname

Given Names

Organisation Name

Address

State Postcode


After Hours

Mobile

Email

APPLICATION FORM

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Interim Residential Care Fee Estimator

Name of Resident

This Fee Estimator is used as a tool to provide Infinite Aged Care with an Interim Means Tested Fee (MTCF) whilst waiting for the Department to provide your approved MTCF based on your Assets and Income Assessment. The actual amount of the fees and charges payable will depend on the results of the Assessment and Infinite Aged Care will make adjustments accordingly once this advice is received by the Department.

All reasonable care has been taken in preparing and designing the Interim Means Tested Fee Estimator based on the My Aged Care Residential Care Fee Estimator; however, Infinite Aged Care provides no warranty and makes no representation that the information provided by this tool is appropriate for your particular circumstances or indicates you should follow a particular course of action. You should consider obtaining independent legal, financial, taxation or other advice to check how the information relates to your particular circumstances.

Infinite Aged Care is not liable for any loss caused, whether due to negligence or otherwise arising from the use of, or reliance on, the information provided directly or indirectly on or through this Estimator.

90 days post admission, if Infinite Aged Care has yet to receive your Department Assessment letter, full fees and charges will apply.

Please note:

• If you choose not to disclose your income and assets the maximum fees will apply.

• If a resident is a member of a couple, please enter combined assets. The calculator will automatically half the value. When the asset is held jointly, or in common, with another person other than the resident’s partner, the value of the asset is taken into be the resident’s interest in the asset.

• If the value of your income and assets varies, so to will your fees and payments.

APPLICATION FORM


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Your Information

Do you have a partner? Yes / No (circle)

Income includes: • Income support payments from the Australian Government such as the age pension or service pension

• Net income from rental property

• War widow / widower pensions and some disability pensions

• Net income from business, including farms

• Income from superannuation income streams such as annuities and allocated pensions

• Overseas pension income

• Family trust distributions

• Dividends from private company shares

Do not include interest from your bank accounts or financial investments. Your financial assets will be deemed to earn a certain rate of income.

Please state your estimated Annual Income including;• Aged care / war widow / widower / disability pensions

• Net income from rental property / Net income from business (including farms)

• Income from superannuation streams such as annuities and allocated pensions, overseas pension income, family trust distributions…

If you have a partner, enter your combined income. $

Homeowner Status

Do you and/or your partner own, or are currently paying off the home you live in? Yes / No (circle)

Your home will be included as an asset unless it is occupied by a protected person. A protected person is:• Your partner or dependent child

• Your carer who has lived with you in the home for the past two years and is eligible for an income support payment

• A close relation, such as a sister, brother, parent, child or grandchild who has lived with you in the home for the past five years and is eligible for an income support payment.

Will a protected person live in the family home? Yes / No (circle)

Net market value of the home Enter the market value of your home less any outstanding mortgages on the home. $

APPLICATION FORM

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Financial Assets

Financial assets include: • Bank, building society and credit union accounts

• Cash

• Term deposits

• Cheque deposits

• Friendly society bonds

• Managed investments

• Listed shares and securities

• Loans and debentures

• Shares in unlisted public companies

• Gold and other bullion

• Gifted assets - if you have gifted amounts above $10,000 in the last year or $30,000 in the last five years, include the amount above these limits as a financial asset.

TOTAL VALUE OF FINANCIAL ASSETS $

Other Assets

Other assets include: • Household contents and personal effects (these are typically valued at $10,000)

• Foreign assets including investments, business interests and real estate

• Investment property

• Special collections such as stamps, art works or antiques

• Superannuation balances

• Private trusts, family trusts and private companies

• Net retirement village entry contributions

• Refundable accommodation deposits

TOTAL VALUE OF OTHER ASSETS $

Debts

A debt is any loan, mortgage, charge or encumbrance held over an asset which has been included as a financial asset or other asset.• Do not include the value of the mortgage over the family home (if there is one)

• Do not include credit card debt or personal loans

If you have a partner, enter your combined debt. $

APPLICATION FORM


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Income and Asset Information

Have you had your Means Test (income / assets) conducted by Centrelink or DVA? Yes / No (circle)If YES, please provide a copy of your assessment from Centrelink or DVA.

If NO, please speak to our friendly staff to obtain the necessary forms for the testing to be completed.

Assets and Income Details

Entering residential aged care for the first time may require completion and lodgement of forms to determine your ability to contribute to the cost of care and accommodation. We have listed and explained these forms below.

Please note that if you receive a means tested income support payment (ie. age pension) and you DO NOT own a home – you also DO NOT need to complete any forms.

1. Residential Aged Care Property details for Centrelink and DVA customers form (SA485)If you receive a means tested income support payment (ie. age pension) and you DO own a home – you need to complete this form (SA485) which looks at key aspects of your property and incorporates the protected person questions (spouse, carer, relative). These details will be used to assess how much you need to pay for care in an aged care home.

2. Residential Aged Care Calculation of your cost of care form (SA457)If you DO NOT receive a means tested income support payment (ie. age pension) – you DO need to complete this form (SA457) in full. This form will ask for you your income and asset details which will then be used to assess how much you need to pay for residential aged care.

These forms need to then be lodged at the Department of Human Services (Centrelink) or Department of Veteran 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.

Please note that if you do not intend lodging a Residential Aged Care Calculation of your cost of care form (SA457) you will be liable for the maximum accommodation price and the maximum means tested care fee on admission regardless of your financial status. Completing this section of the application form 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 in relation to your aged care accommodation costs and ongoing fees.

APPLICATION FORM

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Application for Residential Care Service 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:

1. A copy of your Aged Care Support Plan or referral code.2. A copy of your Aged Care Fees Letter including Assets and Income Summary Statement – if received from the Department of Human Services.3. Photocopy of Pension and Medicare Care.4. Certified Enduring Power of Attorney (attach a complete copy).5. Certified QCAT, NCAT or SACAT – if applicable.6. Certified Advance Health Directive – if applicable. Please note, failure to complete this application document and supply required information may delay the processing of your application.

Lodgement of Combined Assets and Income AssessmentPlease complete one of the following four choices below in regards to your combined income and assets determination.

o I have received an Aged Care Fee advice from the Australian Government that confirms my accommodation costs (copy of the letter and assets summary statement is attached to this application).

o I have lodged the application for the Combined Income & Assets Assessment and I am awaiting advice from the Australian Government.

Date Lodged _____/_____/_____

o I will lodge the application for the Combined Income and Assets Assessment. Proposed lodgement date _____/_____/_____

I understand if I accept a placement prior to being able to produce an aged care fee advice from the Australian Government that you may be charged the full accommodation payment until I provide a copy of the letter.

o I choose not to lodge the application for the Combined Income and Assets Assessment and understand that I will pay the published Refundable Accommodation Deposit or equivalent Daily Accommodation Payment of the room offered at the time of placement and understand I may also be charged the Means Tested Care Fee of up to $219.62 per day (current as at 01/07/19 and subject to change).

APPLICATION FORM


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Completed by: o Applicant o Applicant’s Representative

Surname

Given Names

Relationship to Applicant

Signature

Date _____/_____/_____

Office Use Only

Application Pack Sent o Yes o No

Tour Date Arranged o Yes o No

Follow-up Required o Yes o No

Placement Offered Admission Date _____/_____/_____

Room and bed number allocated

Declaration

Upon signing this application, the applicant consents to:

• Infinite Aged Care acquiring health information from external health service providers, for the purpose of maintaining accurate and current health records.

• Having their photo taken, for identification purposes only.

I sincerely declare that the answers to all of the questions given in this application form (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 Infinite Aged Care 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 the agreement supplied in the event I am offered and accept a placement.

I agree by completing this application to be wait listed for a 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.

APPLICATION FORM

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STATUTORY DECLARATION PLEASE NOTE: this form is not applicable for respite residents and must be signed in the presence of any one witness mentioned at the bottom.

I / We

Of (address) for (resident)

Having checked and understood the information contained in this Asset Declaration Form hereby solemnly and sincerely declare that it is a true and accurate record of my / our Asset Values. This information has been given to enable Infinite Aged Care to determine the extent of any Accommodation Charges due by me / us for entry into Infinite Aged Care facility. I / We understand that Infinite Aged Care will rely on this information when making its decision. I / We understand this form represents part of the Residential Care Services Agreement and I / We accept full responsibility and make good for any loss that may be incurred by Infinite Aged Care as a result of any incorrect or misleading information provided by me / us. I / We, am / are not aware of any other Assets owned by me / us that have not been disclosed on this form. And I / We make this solemn declaration conscientiously believing that same to be true, and by virtue of the provisions of the Oaths Act 1936.

Declared at in the State of

This day of 20

Signature of Applicant Name(s) of Applicant(s)

Relationship to Resident

Signature of Witness (Justice of the Peace, Solicitor, Minister of Religion, Accountant, Medical Practitioner)

Name(s) of Witness

Name(s) of Witness


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MEDIA CONSENT FORM

The Privacy Act 1988 (Cth) imposes obligations upon organisations collecting personal information to protect that information. Images of individuals in photographs or film are treated as personal information under the Privacy Act where the person’s identity is clear or can reasonably be worked out from that image. While these activities are of interest to members of the community and add significantly to the appeal of facility publications and websites, the safety of residents is paramount in all that we do.

From time to time, Infinite Aged Care Pty Ltd ACN 600 107 622 and its associated entities (“Infinite Aged Care”) use images, names and recordings of residents, staff and visitors in its care facilities for marketing, promotional, educational and celebratory purposes. Such images are used in monthly Resident Newsletters and facility marketing material (including social media updates) that show residents in a positive light. While often used for marketing purposes they are also used to acknowledge resident special events, participation in musical performances, life style activities or for specific sharing of a resident’s background or life story. Such sharing and stories greatly benefit all residents in the extended Infinite Aged Care family

Images and recordings may be used in a variety of media (in whole or part), but not limited to, print, film, radio, multimedia uses and internet based material (including company website and social media).

I, ___________________________________ (insert name) at ___________________(facility name) hereby:

1. consent and agree that Infinite Aged Care has the right to take or use photographic images and recordings (including video, sound and written recordings) of me and to use these photographs and recordings unconditionally in any and all media, including but not limited to online and social media, for any purpose whatsoever;

2. confirm my understanding that the photographs or recordings referred in point 1 above may be made available to the public generally, including but not limited to, content producers, advertising and marketing agencies, media outlets, printers and designers. Further the images may be cropped or altered as necessary;

3. release to Infinite Aged Care all rights to exhibit this work in print and electronic form, publicly or privately and to market copies worldwide;

4. waive all rights, claims or interest I may have to control the use of my identity or likeness in the photographs or recordings and agree that any uses described herein will be made without any compensation or additional consideration of me;

5. acknowledge that the material may continue to be used for a number of years, even once the resident has left the facility, and that some of the marketing material that may be created may have extended longevity;

6. acknowledge I may withdraw my permission granted herein by contacting The Proper Officer, Infinite Aged Care, PO Box 8108 GCMC QLD 9726 in writing. I agree that Infinite Aged Care may continue to distribute material containing my photograph, recording or images where that material was prepared, published or communicated before my consent was withdrawn.

The Photo and Media Consent Form will be placed on the resident’s file or record and will be retained by the facility. If requested, a copy of the form will be made available to you.

Resident Name Consent Sort For (please print):

Representative Name If Required (please print):

Signature of Authorised Resident/ Representative:

Date:

Telephone:

Address: State: Postcode:

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PRIVACY CONSENT FORM

I have signed this consent after: a) A member of the organisation has fully explained to me the need for information to be collected, the nature of that information, the purposes for which it will be used and how it will be protected; b) The secondary purposes referred to above have been explained to me; c) I have been given the opportunity to read the Privacy Policy; d) I have had explained to me, the Applicant’s rights to verify information held about the Applicant and the Applicant’s rights to access that information; e) I believe that I fully understand my/the Applicant’s rights to privacy in respect of information collected, used and disclosed about the Applicant and the Applicant’s rights of access to that information.

____________________________________ _______________________________________Signature of Applicant / Power of Attorney /Guardianship Order (please circle)

Witness Signature

_______________________________________Date ____/____/_______ Witness Name & Contact Number

NOTE – The consent given on this Form relates ONLY to the Use and Disclosure of Personal and Health Information given to our organisation. Consent on this Form applies to no other purpose.

Resident Name ________________________________________________________________________

I, ___________________________________________ the Applicant / Power of Attorney / Guardianship Order (please circle) give consent to this Organisation to collect personal and health information eg. from the medical practitioner.

I understand that the purpose of the collection of this information is required to provide services to the applicant. I understand the organisation may use the information that I provide and they obtain, for purposes related to their services and may disclose information to other persons such as specialist medical practitioners or organisations which require the information to provide services directly related to the service the applicant will receive. I have no objection to this. I do not wish the following persons to have information disclosed to them.

_____________________________________________________________________________________

By signing this consent and I acknowledge the following:• I do/do not (please circle) consent to information about me being used for any Secondary Purpose; and• I do/do not (please circle) consent to information about the organisations products and services being sent

to me. Should you have any further questions, to fully understand this policy, please contact us for further explanation.

HEALTH SCREENING (PRE ADMISSION - RESIDENTS)

Dear Incoming Resident,

This health declaration is required to be completed prior to you entering our facility as a resident. We want to do all we can to prevent the spread of Coronavirus (COVID-19) and reduce the risk of exposure to our existing residents and staff where possible.

Please note that this information is requested to ensure that we can maximise the safety and wellbeing of everyone in our community. We will ensure that it is filed and stored confidentially to protect your privacy and confidentiality.

RESIDENT DETAILS

Given Name: Surname:

Phone/Mobile: Facility:

Email:

Planned Admissions Date:

DECLARATION BY INCOMING RESIDENT

1. Have you experienced any of the following symptoms in recent days, please tick relevant box:

☐ Fever ☐ Dry Cough ☐ Body aches ☐ Headaches

☐Sore throat ☐Runny Nose ☐ Tiredness ☐ Shortness of breath

☐ Other, please specify: ____________________________________________________ We reserve our right to request a medical clearance or further health information prior to your admission.

2. Have you been in contact with a confirmed or suspected Coronavirus (COVID-19) patient, family member, friend or close contact in the past 14 days?

☐ Yes ☐ No

If you have answered yes, please understand our need to potentially reschedule your planned admission to a later date when appropriate self-isolation time frames have passed.

3. Have you, or an immediate household member of close contact, travelled overseas or on a cruise ship in the past 14 days?

☐ Yes ☐ No

If yes, please indicate which country(s), date of return and flight details: _______________ ________________________________________________________________________ ________________________________________________________________________ If you have answered yes, please understand that a risk assessment will occur and you may need to self-isolate and delay your admission until an appropriate future date.

SIGNATURE

Signature: Date: / /

Print Name of

Resident/Representative:

EDMONTON GARDENS 5 Bruce Highway Edmonton QLD 4869

HAHNDORF RESIDENTIAL CARE SERVICE 1a Main Street Hahndorf SA 5245

INFINITE CARE IPSWICH 43 South Street Ipswich QLD 4305

INFINITE CARE MOUNT LOFTY 69 Stuart Street Mount Lofty QLD 4350

KLEMZIG RESIDENTIAL CARE SERVICE Leighton Avenue Klemzig SA 5087

ROSE COURT AGED CARE FACILITY 3 Grant Avenue Gilles Plains SA 5086

HEAD OFFICE Suite 6, Level 3, 128 Bundall Road Bundall QLD 4217

CARAVONICA WATERS 15-17 Lake Placid Road Caravonica QLD 4878

CHRISTIES BEACH RESIDENTIAL CARE SERVICE 50 Gulfview Road Christies Beach SA 5165

THE CHURCHILL RETREAT 470 Churchill Road Kilburn SA 5084

INFINITE CARE CORNUBIA 144 Beenleigh- Redland Bay Rd Cornubia QLD 4130

EDGE HILL ORCHARDS 15 Oregon St Manoora QLD 4870

Admission Application - Infinite Care · 2020. 6. 15. · o Partner deceased o Partner separated o...

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