Application for Admission

This application requires that you provide the following:

• Personal Information;
• Information about your financial position that is necessary for us to determine your likely Fees and Charges;
• Accommodation Information; and
• A Declaration stating that the information you provide to us in this application is true and correct.

If we can offer you a place and you decide you wish to enter the service, you will need to sign a resident agreement. The Resident Agreement outlines your and our rights and responsibilities if you enter our Service.

The financial information you record in this application should accompany or be used completing a 'Request for an Assets Assessment' or Income Assessment form (if necessary) to the relevant Agency (Department of Human Services, Centrelink or Department of Veteran Affairs). This will enable Centrelink or the Department of Veteran Affairs to work out how much you need to contribute to the costs of your care and accommodation. If you do not wish to provide us with any financial information you do not have to but if you do not provide that information we will need to charge you the maximum amount permissible under the Aged Care Act 1997 (Cth) for your care and accommodation.

We will comply with the provisions of the Privacy Act 1988 (Cth) and the Australian Privacy Principles in dealing with the information you provide to us with this application. The information we collect may be used for an purpose that is directly related to our functions or activities as an aged care provider or as otherwise permitted at law. For more information on how we handle your personal information, you may review the Privacy Policy and Collection statement. Both of these documents are available at our Service.

A decision to enter Aged Care is a significant decision. We encourage you to seek independent legal, financial and other advice about the nature and effect of this application, the Resident Agreement and living in the Service.

If you wish to proceed, please complete this form and provide us will all of the information we have requested in the application.

Your progress in this online application is saved and you can return at any time.

Your Personal Details

Your Representative's Details

Emergency Contact Details

Who should we contact regarding your application?

Pension and Benefit Details

Medicare Details

Medical Details

Full medical details will be required on admission or when signing the Resident Agreement

Who is your current General Practitioner / Medical Professional?

Present Living Arrangements

Aged Care Assessment Team Approval

Overview

If you are applying to receive respite care you do not need to complete this section of the Application.

If you choose to complete the following details, we will be able to provide you with the likely fees and charges you might be eligible to pay.

If you ask us, we can provide you with an estimate of the maximum amount we can charge you for care and accommodation. We cannot advice you of the exact amount you will be require to pay until the Department has completed the assessment of your ability to contribute to the cost of your care and accommodation.

If you are apply for an income and asset test with the Department of Human Services/Centrelink, you will be required to complete and lodge the relevant form with them. The Department will also make an assessment on your ability to contribute to the cost of your care and accommodation.

You are not required to apply for an income and asset test before entering our Service. However, if you do not apply for an income and asset test we will need to charge you the maximum permitted under the Aged Care Act 1997 (Cth) for your care an accommodation which is set out in the attached Schedule of Fees and Charges.

Please ensure all questions are answered and that you do not leave any blank spaces. Please also make sure you complete the Statutory Declaration at the end of this application form.

Your means (income and assets) assessment

Your assets

Married/De facto couples need only declare 50% of their assets.

Your annual income

There are (3) fees which may be applicable to you based upon the level of your assets and your income.

The (3) fees applicable to you will be for:

1. BASE DAILY FEE
2. COST OF ACCOMMODATION
3. COST OF CARE

1. BASE DAILY FEE

This is charged at 85% of the Australian Aged pension. All residents will pay this fee.

2. COST OF ACCOMMODATION

Before you enter care: if you wish to be supported by the government, you MUST complete the request for assets assessment and send it Centrelink/DVA. You will receive written notification indicating your supported status. Once you have entered care the department of Social Services will inform Saint Nicholas if you are eligible to pay accommodation costs and what they will be.

Centrelink will notify you of your supported status for purposes of determining your cost of accommodation fees. You will be either:

• Fully Supported - the cost of your accommodation will be fully subsidised by the Government.
• Partially Supported - As a partially supported resident you may be eligible for some support from the government. You may be required to pay a partial accommodation cost as determined by the Department of Social Services.
• Non-supported - if you have assets higher than the Centrelink determined level or income higher than the Centrelink determined level you will not be supported for the cost of accommodation by the Government and the information below will be relevant to you.

Saint Nicholas charges Refundable Accommodation Deposits (RAD):

• • $450,000 for Premium single room accommodation
  • $400,000 for Superior single room accommodation
  • $350,000 for Classic single room accommodation
  • $300,000 for twin shared room accommodation
  • $250,000 for Quad shared room accommodation

Please note that these are fully refundable deposits when you leave the facility.

In all these cases the RAD does not need to be paid upfront.

You may choose to pay the equivalent daily charge known as the Daily Accommodation Payment (DAP).

The DAP is charged at the Maximum Permissible Interest Rate (MPIR) (please note this rate is indexed quarterly and the scheduled (MPIR) will be applicable from the date of admission). Once admitted the MPIR will remain unchanged for the duration of your residency.

We have outlined the following examples based on an MPIR of 6% at the date of admission. This being said you can choose to pay:

• • RAD of $450,000 or the equivalent DAP of $73.97/day
  • RAD of $400,000 or the equivalent DAP of $65.75/day
  • RAD of $350,000 or the equivalent DAP of $57.53/day
  • RAD of $300,000 or the equivalent DAP of $49.32/day
  • RAD of $250,000 or the equivalent DAP of $41.10/day

You may also choose a combination of both RAD and DAP in any combination you choose. We'll use 2 examples based on the MPIR of 6%:

• • Example 1 - Let's say you enter into a $400,000 room you can choose to pay say $300,000 as a RAD and you will be charged the DAP on the remaining $100,000 at 6% which would be $16.44/day. Hence you will pay $300,000 upfront and a daily payment for $16.44/day
  • Example 2 - The same RAD $400,000 you choose to pay $150,000 as a RAD and you will be charged the DAP on the remaining $250,000 at 6% which would be $41.10/day. Hence you will pay $150,000 upfront and a daily payment of $41.10/day

N.B. When paying a RAD or DAP you may choose any combination that suits you. When you are eligible to pay a RAD or DAP you MUST agree to the amount of the RAD before admission then you have 28 days to let us know how you intend to pay by either RAD, DAP or combination of both. You may also choose to pay a smaller RAD and have the DAP drawn down out of the RAD.

We cannot guarantee that all rooms will be available at the time you decide to enter the service.

3. COST OF CARE

The Department of Social Services will assess your means (combination of income and assets) after entry to Saint Nicholas and determine if you are eligible to pay a means tested care fee in addition to the above two fees. You will be notified in writing by the department after entering aged care as will Saint Nicholas Nursing Home.

For further information about your fees please contact Department of Social Services FINANCIAL INFORMATION SERVICE on 132 300 or 1800 200 422. They will be able to give you specific information for your particular circumstances. More information is available on the Department of Social Services website www.myagedcare.gov.au

Alternatively you may wish to seek independent financial advice. We have included some brochures for financial advisers in the application package should you wish to use them.

Saint Nicholas is unable to provide financial advice however we will be happy to assist you with providing information regarding fees and charges.

Within 7 days of receipt of a written request from you, we will provide you with information and documents set out in the Act about our compliance, storage, and use of Refundable Deposits and Accommodation Bonds for the previous financial year of when you enter into a Resident Agreement.

If your Accommodation Payment or Accommodation Contribution includes payment by Refundable Deposit, then in addition to the above, we will also provide you with a copy of your entry in the refundable deposit register made in accordance with the Aged Care Act 1997 (Cth).