Blue Care Permanent Application

HomeBlue Care Permanent Application

This application form, once completed can be used to apply for entry into any of Blue Care’s 57 residential aged care facilities throughout Queensland and northern New South Wales.

  • The information you provide on this application form is information that Blue Care requires to assess your
    needs and priority for entry into residential aged care, whether for permanent or respite care.
  • Additional information is available about aged care from the Department of Social Services on
    1800 200 422 or their website myagedcare.gov.au
  • Please use a black pen and write in BLOCK LETTERS and, where indicated, tick the box and write a
    comment.
  • To find an aged care facility near you, refer to the attached Residential Aged Care Directory or visit
    www.bluecare.org.au and select Our Services – Residential and then click on the link to find the nearest
    Blue Care centre.
  • For assistance with the completion of the Permanent Application Form, please do not hesitate to contact
    our customer service representatives on toll-free number 1800 838 929.
  • A complete application (all documents) is required by Blue Care to proceed to the wait list.
Are you applying for
1. Current location
2. Applicant details (person requiring residential care)
3. Details of Applicant’s representative - first contact
4. Details of Applicant’s representative - second contact
5. Details of your Enduring Power of Attorney (EPOA)
Details of Attorney
Other EPOA details
6. Details of your nominated guarantor - please ensure you have completed and attached a signed copy of the guarantor authority letter
7. Your aged care facility preferences

It is recommended you contact the aged care facilities you have listed as preferences, to view them. When a suitable bed becomes available, an admissions officer will contact the EPOA/Applicant to offer a bed; we will be seeking your immediate acceptance of this offer.

8. Do you receive community services in the home?
9. Existing/previous permanent resident of an aged care facility

Please supply a copy of the Service Agreement and current care plan from the aged care facility with this application form.

10. Responsibility for paying accounts and receiving correspondence
11. Financial Information - Income (Pensions)
12. Financial Information

Respite residents do not need to complete this part of the application.

The Combined Asset and Income Assessment is used by providers to determine two fees – the means tested fee and the accommodation price that has to be paid.

Details of Assets and Investments of the Applicant
Joint assets for partners/spouse are split 50/50 when determining assets values for applications on this form. Applicant $ (a) Applicant's Partner $ (b) *Total $ (a + b)
Bank Accounts, Building Society and Credit Union accounts
Interest Bearing Deposits and Fixed Deposits Accounts
Bonds; Debentures and Shares; Superannuation Assets from which lump sums may be withdrawn
Investments in Property Trusts; Friendly Societies; Equity Trusts; Mortgage Trusts and Bond Trusts
Home/Unit – Market Value
Retirement Living Unit – Refund of Ingoing Contribution (Exit Entitlement)
Other Properties/Land
Other (e.g. Gifting within last 5 years)
TOTAL VALUE OF ASSETS $
LESS Loans to be repaid $
GROSS ASSETS $
13. Property Assets and Carer Status

Respite residents do not need to complete this part of the application.

Property Assets

The following information is required to enable us to determine whether the main residence will be considered as an asset of the Applicant.

1) Do you own or part-own the house, unit or flat in which you normally live?

Your home may be excluded, please answer the following questions:

2) Do you have a spouse or dependent child living in your home?

If yes, please indicate who is living in your home:

3) Have you had an immediate family member who receives, or is eligible to receive, the Carer’s Pension, Aged Care Pension or other income support payment, living in your home for at least the past two years? (An example of other income support payment might be a disability pension).

Please note the Carer’s Pension is distinct from the Carer’s Allowance, which does not qualify

4) Have you had a close family member or friend who receives, or is eligible to receive, the Carer’s Pension or other income support payment, living in your home for at least the past five years?
(Examples of close family members include aunts/uncles or niece/nephew).

Please note the above comments about types of payments.

When a suitable bed becomes available, the Applicant/EPOA will be required to sign a residential agreement prior to or on the date of admission. Your guarantor will also be required to have signed by this date. Admission will NOT proceed until we receive the agreement, signed as required. To assist you in this process, we can send you a blank copy of our residential agreement for you to review and obtain legal and financial advice on. We will send you a personalised residential agreement with specific fee and facility information at the time of offer.

Application Checklist

Please ensure you have obtained/completed all of the following documents:

1. Permanent Application Form.

2. Guarantor authority letter/s - please see enclosed fact sheet.

3. Aged Care Client Record (a copy is not required if assessment completed after 2012).

4. Statement of Value of Assets/Combined Assets and Income Assessment - your reply letter from Centrelink/DVA (all pages) - if assets are under $155,823.20.

5. Photocopy of Pension and Medicare card.

6. Certified Enduring Power of Attorney (attach a complete copy) - Please see enclosed fact sheet.

7. Certified QCAT or NCAT - if applicable.

8. Certified Advance Health Directive - if applicable.

A complete application (all documents) is required to proceed to the wait list.

If a Combined Assets and Income Assessment form has been provided in your pack, please post the completed form to either Centrelink or DVA at the address listed on Page 2 of the form.

Declaration

Upon signing this application, the Applicant consents to:

a) Blue Care acquiring health information from external health service providers, for the purpose of maintaining accurate and current health records.

b) Having their photo taken, for identification purposes only.

I sincerely declare that the details supplied on this application form, whether for myself or on behalf of the applicant, and in particular those questions in regard to the financial details of the applicant, are to the best of my understanding true and correct, and in no way inaccurate, incomplete, misleading or deceptive. I have provided Blue Care with, or I will provide upon request, all further information and documentation required for this application, including any further proof of financial status.

Full name: (please print)______________________________________________ Completed by: Applicant: Applicant’s representative:
Signature:.................................................... Date: / /

If you need assistance, then please do not hesitate to contact one of our customer service representatives on the number below. Please post the above documents to us in the enclosed reply paid envelope, or email to admissions@bluecare.org.au

All Residential and Respite Aged Care enquiries to:

Ph: 1800 838 929

Fax: 07 3327 5651

Email: admissions@bluecare.org.au

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