THE PIONEERS LODGE
ADMIN 4-1APPLICATION FOR PERMANENT RESIDENCY
ATTACHMENT 2
This Application is for admission to: Pioneers Lodge
SURNAME:______
GIVEN NAMES:______
MALE OR FEMALE:______
DATE OF BIRTH:______
PLACE OF BIRTH:______
ABORIGINAL OR TORRES
STRAIT ISLANDER ORIGIN:______
MARITAL STATUS:______
RESIDENTIAL ADDRESS:______
POSTAL ADDRESS:______
PHONE NUMBER:______
EMAIL:______
MEDICARE NO:______
(Please attach a copy of the Medicare Card)
PENSION NO/VET AFFAIRS:______
(Please attach a copy of the Pension Card)
PENSION TYPE: ______
(e.g. Aged, Disability, Full, Part)
Have you received services at home? YES/NO Details: ______
Has an Aged Care Client Record (ACCR) been completed by the Aged Care Assessment Team (ACAT)? YES/NO
If yes, please attach a copy.
If No, please make arrangements for this to be done before lodging the Application form by phoning 1800 200 422.
Has a "Permanent Residential Aged Care Request for aCombined Asset and Income Assessment" form been lodged with Centrelink/DVA. YES/NO
If Yes, please attach the information received from Centrelink/DVA
If No, please contact Centrelink/DVA for a "Permanent Residential Aged Care Request for a Combined Asset and Income Assessment" or download the form from and attach theinformation you receive from Centrelink/DVA.
Do you have a Power of Attorney? YES/NO If yes, please attach a copy
Do you have an Enduring Guardian? YES/NO If yes, please attach a copy
Residents Representative:
Name: ______Relationship to Applicant: ______
Address:______
______
Business Phone: ______
Home Phone: ______
Mobile: ______
Email:______
Alternative Contact:
Name: ______Relationship to Applicant: ______
Address:______
______
Business Phone: ______
Home Phone: ______
Mobile: ______
Doctor’s Name: ______Phone No: ______Name of Pharmacy: ______
Religion: ______
Main Language: ______
Known Allergies: ______
Known Reactions: ______
(to medication/food etc.)
Special Diet: ______
Signature: ______Date: ______
______
Checklist for lodging Application Form
Copy of POA attached□
Copy of Enduring Guardian attached□
Copy of Aged Care Client Record attached □
Copy of Income & Asset Assessment attached□
Copy of Medicare Card attached□
Copy of Pension Card Attached□
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OFFICE USE ONLY
ACCR suppliedYES□NO□
High Care□Low Care□Low Care Dementia Specific□
Permanent□Respite□Commencement date forapproval ______
Income & Asset Assessment Information:
Basic Daily Fee$ ______
Means tested care fee$ ______
Accommodation Payment$______
ADMINISTRATION 4-1/PERMANENT-HIGH/LOW CARE March 2017 1