Registration Enquiry

Please complete and submit this online form to check your eligibility.

Form Reference Number 6

Does the Person have a Home Care Package? *

Name of Home Care Package Provider

Email Address of Provider

Case Managers Details

Aged Care Number of Consumer

Title *

First Name *

Surname *

Preferred Name

Country of Birth

Language

Date of birth *

Street Address *

City

ZIP / Postal Code

Postal Address (if different from above)

City

ZIP / Postal Code

Phone Number *

Mobile

Email Address

Are you registered with My Aged Care? *

Aged Care User ID

My Aged Care Referral Code (if available)

Residency Type *

Owner / Landlord / Agency Name (if applicable) *

Postal Address

Suburb and Postcode

Phone

Mobile

E-Mail

Living Arrangements *

Disability Indicator *

ATSI Status *

Country of Birth *

Language Spoken at Home *

Department Of Veteran Affairs *

Pension Type *

Pension Number

Medicare Number *

Are you receiving a Home Care Package? *

Home Care Package Level

Home Care Package Provider

Are you registered with the NDIS? *

Do you have a carer? *

Carer Residency Status

Are they receiving a carers pension?

Carers Name

Carers Date of Birth

Phone

Mobile

Relationship to client

Emergency Contact Person *

Phone *

Mobile

Relationship to client *

I accept the privacy statement *

Privacy Statement

Home Assist Community Services is collecting your personal information to assess your eligibility for Home Assist Community Services funded programs. We will not disclose your personal information outside of Home Assist Community Services unless we are required by law. By providing your consent you agree to sharing this information with our assessors to support your application.

By completing and submitting this form, it is acknowledged that you have given us your consent to manage your personal information in the manner described in Home Assist Community Services full Privacy Policy and this condensed Privacy Statement. For a copy of Home Assist Community Services Privacy Policy please contact our office during business hours.

NOTE: Home Assist Community Services may be at times requested to share your information with Queensland Department of Housing and Public Works, Australian Government Department of Health, Queensland Health, Department of Veterans' Affairs, My Aged Care, NGO's and other Government bodies. We may need to at times de-identify your name when we are asked to provide auditing bodies as required by law for the purpose of reporting and data matching.

Your personal information is stored in a manner that reasonably protects it from misuse and loss and from unauthorised access, modification or disclosure.

When your personal information is no longer required for the purpose for which it was obtained, we will take reasonable steps to destroy or permanently de-identify your personal information. However, most of the personal information is or will be stored in client files which will be kept by us for a minimum of 7 years.

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133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

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