Application to vary conditions of allocation

This application form replaces the previous four forms: Application for a variation of provisional allocation of places, Application for a variation of conditions of allocation ̶ residential respite, Application for a variation of conditions of allocation ̶ residential, home and

flexible care places. Combining Services (residential aged care and home care services only)

Name of approved provider:     

Postal address of approved providerStreet address / PO Box:      Suburb:      State:      Postcode:      

Business address (home care places) / location (other places) of aged care service to which the allocation currently relates (if different to above)Street address:      Suburb:      State:      Postcode:      

Key personnel for this applicationTitle:      Given name(s):      Family name:      Position:      Contact phone:     Email address:      

Service ID:      Name of the aged care service:      

If you have any questions about completing this form, please phone 1300 653 227 and ask for aged care services in your state or territory office. If you require more room, please attach additional pages. Please ensure any additional pages are clearly labelled with your details and refer to the specific question.

Note: You may be contacted by the Department to discuss your application. The Department may, at its discretion, request documentation to support your claims.

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Part A – Details of the places to be varied

A1. Is this an application with respect to a provisional allocation?

Yes

No

A2. Please indicate the care type that is the subject of this application, and please provide the number of places in relation to which you wish to vary conditions:

Type of place (please tick) Total Number of Places Please tick

Residential Care(including Respite)

      Adjusted Subsidy Places

Extra Service Status

Respite Care

Home Care Level 1:     

Level 2:     

Level 3:     

Level 4:     

Flexible Care Multi-purpose

Service (MPS) Innovative Pool Transition Care

MPS:     

Innovative Pool:     

Transition Care:     

A3. If the places have been allocated to provide a particular type of aged care, will that type of aged care continue to be provided after the variation?

Yes

No

N/A

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A4. Please specify:

(1) the conditions allocation to be varied; and(2) the proposed variation.

     

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A5. Please provide details of the effect that the proposed variation/s will have on care recipients.

     

A6. What is the proposed variation day? dd/mm/yyyy

A7. Is the proposed variation day less than 60 days from the date of this application?

Yes

No Please go to A9.

A8. Please specify the reason.

     

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A9. Please provide details of the financial viability of your aged care service.

     

A10. After the variation would the places be included in a different aged care service?

Yes

No Please go to A12.

A11. Please outline the financial viability of this service.

     

A12. After the variation, would the care provided in respect of the places be provided at a different location?

Yes

No Please go to A15.

A13. What is the address of the proposed new location?

Street address:      Suburb:      State:      Postcode:      

A14. Please set out the suitability of the premises used, or proposed to be used, to provide care through the aged care service.

     

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A15. Please set out your proposal to ensure that care needs are appropriately met for care recipients who are being provided with care in respect of those places.

     

A16. If any of the places specified in A2 were allocated to meet the needs of people with special needs1, will those needs continue to be met after the transfer?

Yes

No

N/A

1 People with special needs has the meaning given in section 11-3 of the Act and includes people: from Aboriginal and Torres Strait Islander communities; from culturally and linguistically diverse backgrounds; who live in rural and remote areas; who are financially or socially disadvantaged; who are veterans; who are homeless or at risk of becoming homelessness; care-leavers; parents separated from their children by forced adoption or removal; or who are lesbian, gay, bisexual, transgender or intersex.

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Part B – For applications to change the location only – all types of careIf the question does not apply, please write ‘Not Applicable’.

B1. Are you proposing to construct or develop premises to accommodate the relocated places at the new location?

Yes Please go to B2

No Please go to Part C

B2. Please provide a description of the project (include size, suitability, topography – the features of the surrounding land – and any heritage site issues).

     

B3. What is the total estimated cost of the project? $ ________________________

B4. What are the ownership arrangements of the new site?

     

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B5. How is the land around the site being used?

     

B6. Are there any proposals before an authority in the State or Territory concerned about the use of the site (for example, proposals to rezone the site)?

Yes

No

If yes, please detail below.

     

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B7. Please describe the characteristics of the neighbourhood, including the location of shops, and availability of public transport and community services.

     

B8. Please provide a detailed timetable for calling tenders, planning and construction, and an indication of your ability to meet the timetable.

     

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Part C – For combining residential aged care and home care services only

C1. Please indicate which service (and its RACS ID or ACMPS ID) is preferred to be treated as the ‘continuing’ service in the aged care payment system (SPARC). This is the service to which the places are proposed to be relocated.

Name of continuing service:

Address of continuing service:Street address / PO Box: Suburb: State: Postcode: RACS ID or ACMPS ID of continuing service:

C2. Please indicate below the service (and RACS ID or ACMPS ID) preferred to be closed in SPARC. This is the service from which the places are proposed to be relocated.

Name of service to be closed:

Address of service:Street address / PO Box: Suburb: State: Postcode: RACS ID or ACMPS ID to be closed:

Note: If additional services are to be combined please attach information for these services.

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C3. What are the reasons for combining services?

     

C4. Are any of the preferred continuing service places that are proposed to be relocated adjusted subsidy places?

Yes

No

NA (Home Care)

How many? ____________RACS ID/ACMPS ID: ________________________

Note: If additional services are to be combined please attach information for these services.

C5. Do any of the places in the preferred continuing service, or a distinct part of the service, have Extra Service Status (ESS)?

Yes

No

How many? ___________RACS ID/ACMPS ID: ________________________

C6. If yes, do you intend for the relocating places to have extra service status?

Yes

No

C7. Will the other places already in the continuing service be able to form one or more distinct parts of the service after the relocation?

Yes

No

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C8. Do any of the places in the service preferred to be closed, or a distinct part of the service, have ESS?

Yes

No Please go to C10.

How many? _______________RACS ID: ________________________Note: If additional services are to be combined please attach information for these services.

C9. If yes, do you intend for the relocating places to retain ESS?

Yes No

C10. If the service that will be the continuing service has ESS, is this status to continue?

Yes

No

N/A (The continuing service does not have ESS.)

C11. If ESS is to be moved to the continuing service, please attach ESS conditions and evidence that the conditions will be met (as per the original ESS application). Note: If you are proposing to move ESS to the continuing service the Department will contact you where additional information/evidence is required.

If no, a separate letter to the Secretary requesting revocation of ESS should be attached.

Please note, if a new name has been requested for the continuing service, approved providers need to comply with any state or territory government requirements for changing the service’s name.

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Part D – Declaration – All applicants to sign

This application must be signed only by those persons who are legally authorised to sign for and on behalf of the approved provider. A person who gives information to a Commonwealth entity, or to a person exercising powers or performing functions under, or in connection with, a law of the Commonwealth, or gives the information in compliance or purported compliance with a law of the Commonwealth, and does so knowing the information is false or misleading, or omits any matter or thing without which the information is misleading, may be guilty of an offence under the Criminal Code Act 1995.

I/We declare that all the information set out in all sections completed in this application, and any associated attachments, is true and complete.

I/We declare that the key personnel in my/our service are, and will continue to be, suitable to provide aged care and are not disqualified individuals.

I/We consent to the Secretary of the Department of Social Services obtaining information and documents from other persons or organisations, including the Australian Aged Care Quality Agency and state, territory and Australian Government Departments/authorities, to assist in assessing the application.

Name:______________________________________________________________

Position:____________________________________________________________

Signature:______________________________Date:_________________________

Name:______________________________________________________________

Position:____________________________________________________________

Signature:_______________________Date:________________________________

Please send the completed form to the Department

By post: Aged Care BranchDepartment of Social ServicesGPO Box 9820In the capital city of the state or territory in which the aged care service is located.

By email: To the state office in which the aged care service is located.QLDplaces@dss.gov.au; NSWplaces@dss.gov.au; VICplaces@dss.gov.au; TASplaces@dss.gov.au; SAplaces@dss.gov.au; WAplaces@dss.gov.au; NTplaces@dss.gov.au.

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If you have any questions about completing this form, please phone 1300 653 227 and ask to speak with a Departmental Officer in aged care in your state or territory office.

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