Register or amend for Aged Care Online Claiming using Web Forms

Register for or amend
Aged Care Online Claiming using Web Forms
Purpose of this form
Filling in this form
This form is to be used by Aged Care providers registering for or
amending Aged Care Online Claiming using Web Forms.
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this
with a ✓ or 7
Providers who want to participate in Aged Care Online Claiming
must complete this form for each service. Access will be granted
to each individual service and appropriate staff as indicated on this
application.
• Where you see a box like this
Go to 5 skip to the question
number shown. You do not need to answer the questions in
between.
If a person has previously been authorised and issued with a
Public Key Infrastructure (PKI) Registration Authority number or an
Aged Care User ID (possibly with another service) include this number
in the appropriate section of this form.
Returning your form
This form can only be signed by key personnel of the approved
provider as defined in the Aged Care Act 1997.
Send the completed form to:
Check that you have answered all the questions you need to answer
and that you have signed and dated this form
Aged Care Payments team
Department of Human Services
GPO Box 9923
Authorisation levels for Residential care and Home care
nominated users:
Residential care level 8 and Home care level 10 gives authority to:
• lodge data (used by file upload services only)
• view submitted web forms
• view care recipient information
• view a care recipient profile including associated web forms
• view current and historical claims for the nominated service on
this form.
Residential care level 12 and Home care level 12 gives authority to:
• view latest and historical payment statements for the nominated
service on this form.
Residential care level 13 and Home care level 14 gives authority to:
• register (new) web forms
• update (correct) web forms
• delete (reverse) web forms.
For services located in:
ACT, NSW, QLD and WA send to: SYDNEY NSW 2001
or fax to: 02 9895 3031
or scan and email to:
[email protected]
NT, SA, TAS and VIC send to: MELBOURNE VIC 3001
or fax to: 03 9605 7395
or scan and email to: [email protected]
Reason for application
1 I would like to:
Tick ONE only
If Residential care level 13 is selected, access to level 8 is automatic.
Amend an existing registration
If Home care level 14 is selected, access to level 10 is automatic.
Create a new registration
Service details
For more information
For more information about Aged Care go to our website
humanservices.gov.au/healthprofessionals or for assistance
completing this form email:
2 Service name
For services located in ACT, NSW, QLD and WA:
[email protected]
3 Service ID
Note: This section must be completed.
www.
For services located in NT, SA, TAS and VIC:
[email protected]
4 Service type
or call 1800 195 206 between 9.00 am and 5.00 pm, Monday to
Friday, Australian Eastern Standard Time.
Residential
Home care
Note: Call charges apply from mobile phones.
5 Address
AC004.1307 (formerly 2505)
1 of 6
Postcode
6 Contact person’s name (service manager or equivalent)
Nominated users
15List the nominated users below.
7 Daytime phone number
(
Nominated user 1
)
Nominated user’s name
Fax number
(
)
Email
Daytime phone number
(
)
@
Email
8 Would you like to use the above email address to subscribe to:
Tick ALL that apply
Aged Care eNews
eNews alerts
@
Would you like to use the above email address to subscribe to:
Tick ALL that apply
None of the above
9 Are you both the service contact person and a nominated user?
No Go to 15
Yes 10PKI Registration Authority number (if applicable)
Aged Care eNews
eNews alerts
None of the above
PKI Registration Authority number (if applicable)
11Aged Care User ID (if applicable)
Aged Care User ID (if applicable)
A
A
12Authorisation levels
For information on authorisation levels, refer to page 1.
Residential8
12
13
Home care
10
12
14
13Date of effect
The date the user will have access to the system.
/
/
14End date with service (optional)
Date of effect
The date the user will have access to the system.
/
Provide the date to advise us if a user has access for a specified
time period.
/
Authorisation levels
For information on authorisation levels, refer to page 1.
12
13
Residential
8
Home care
10
12
14
End date with service (optional)
Provide the date to advise us if this user has access for a
specified time period.
/
/
AC004.1307 (formerly 2505)
/
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/
Nominated user 3
Nominated user 2
Nominated user’s name
Nominated user’s name
Daytime phone number
(
)
Daytime phone number
(
)
Email
Email
@
@
Would you like to use the above email address to subscribe to:
Tick ALL that apply
Would you like to use the above email address to subscribe to:
Tick ALL that apply
Aged Care eNews
Aged Care eNews
eNews alerts
eNews alerts
None of the above
None of the above
PKI Registration Authority number (if applicable)
PKI Registration Authority number (if applicable)
Aged Care User ID (if applicable)
Aged Care User ID (if applicable)
A
A
Authorisation levels
For information on authorisation levels, refer to page 1.
12
13
Residential
8
Home care
10
12
14
Authorisation levels
For information on authorisation levels, refer to page 1.
12
13
Residential
8
Home care
10
12
14
Date of effect
The date the user will have access to the system.
Date of effect
The date the user will have access to the system.
/
/
/
End date with service (optional)
Provide the date to advise us if this user has access for a
specified time period.
/
End date with service (optional)
Provide the date to advise us if this user has access for a
specified time period.
/
AC004.1307 (formerly 2505)
/
/
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/
Service contact person(s) details
Nominated user 4
16Provide details of the nominated person(s) who will receive held
Nominated user’s name
and rejected reporting and payment statement email notifications.
Service contact person 1
Daytime phone number
(
)
Contact person’s name
Email
Daytime phone number
(
)
@
Email
Would you like to use the above email address to subscribe to:
Tick ALL that apply
Aged Care eNews
eNews alerts
None of the above
@
Service contact person 2
Contact person’s name
PKI Registration Authority number (if applicable)
Daytime phone number
(
)
Aged Care User ID (if applicable)
Email
A
Authorisation levels
For information on authorisation levels, refer to page 1.
12
13
Residential
8
Home care
10
12
14
@
Service contact person 3
Contact person’s name
Date of effect
The date the user will have access to the system.
/
Daytime phone number
(
)
/
Email
End date with service (optional)
Provide the date to advise us if this user has access for a
specified time period.
/
/
If you have more than 4 nominated users, attach a
separate sheet with details.
AC004.1307 (formerly 2505)
4 of 6
@
Terms and Conditions for Aged Care Online Claiming
using Web Forms
f) Human Services may at any time, at its absolute discretion,
restrict, suspend or terminate my access to Aged Care Online
Claiming with Human Services, whether because of a breach
of these terms and conditions or for any other reason
17In these terms and conditions, a reference to ‘I’, ‘me’ or ‘my’
is a reference to the applicant/s agreeing to these terms and
conditions and all parties acting on their behalf.
g) I may terminate this agreement with Human Services by giving
written notice to Human Services. I understand that I will not
be able to conduct transactions with Human Services using
Aged Care Online Claiming after I give such notice
1. I agree to:
a) comply with these terms and conditions for Aged Care Online
Claiming
h) if this agreement is terminated, my obligations under these
terms and conditions will continue in respect of any claims
I made using Aged Care Online Claiming before the date of
termination
b) ensure that all information I provide, and representations I
make, to the Australian Government Department of Human
Services (Human Services) are complete and accurate
i) I must maintain an electronic record (in a retrievable and
readable form) of all Aged Care Online Claiming transactions
as required by the Aged Care Act 1997
c) promptly notify Human Services in the event that I consider
any information provided, or representations made, by me is
or may be incorrect or misleading (giving false or misleading
information is a serious offence under the
Criminal Code Act 1995)
j) I must promptly notify Human Services of all changes to
authorised persons, including the removal of previously
authorised person or the addition of a new person
d) use a version of a software product approved by Human
Services when conducting a transaction with Human Services
using Aged Care Online Claiming. I understand that Human
Services may revoke its approval of a version of a software
product at any time
k) I must ensure I have appropriate business and security
controls in place to ensure all claims, forms and other
documentation submitted to Human Services, whether using
Aged Care Online Claiming or otherwise, are appropriately
authorised
e) keep my Aged Care User ID, password and any security details
related to my access confidential and secure
l) any use of Aged Care Online Claiming in respect of an Aged
Care Service (that is the subject of this application and terms
and conditions) is taken to be a use of Aged Care Online
Claiming by me
f) immediately notify Human Services in writing if my user
identification, or any associated passwords or identification
issued by Human Services in relation to my access to Aged
Care Online Claiming, is compromised in any way
m) I must notify Human Services in writing as soon as I become
aware that an unauthorised person has submitted claims,
forms or other documentation to Human Services, whether
using Aged Care Online Claiming or otherwise
g) sign and secure all communications I send to Human Services
for Aged Care Online Claiming using my user identification and
associated password (valid at the time of the dispatch of the
communication) issued by Human Services.
n) where, as a result of claims or forms submitted by me using
Aged Care Online Claiming or otherwise, an amount is paid
to me that represents an overpayment under the Aged Care
Act 1997, Human Services may, at its discretion, deduct an
amount equal to the overpayment from subsequent amounts
which may be payable to me.
2. I agree that:
a) Human Services may from time to time change its technical
requirements in relation to the use of Aged Care Online
Claiming, which may require me to change my user
identification or associated passwords
3. These terms and conditions are issued under and are to be
construed in accordance with the laws in force from time
to time in the Australian Capital Territory. All parties submit
to the exclusive jurisdiction of the courts of the Australian
Capital Territory and courts of appeal from them. Neither
party will object to the exercise of jurisdiction by those
courts on any basis.
b) Human Services is not responsible for any costs, losses or
damage I incur in connection with Aged Care Online Claiming
(including, without limitation, communication costs, support
costs, software acquisition or losses associated with Aged
Care Online Claiming being from time to time inoperative or
inaccessible)
c) Human Services may change or add to these terms and
conditions at any time, by giving me notice by mail, by
fax or electronically. A message sent to my business
email address (as held in Human Services’ records)
or by notice published on Human Services’ website
humanservices.gov.au/healthprofessionals is one way of
giving me notice electronically
www.
d) if I use Aged Care Online Claiming after I have been notified of
a change or addition to these terms and conditions, I will be
taken to have agreed to that change or addition in respect of
all uses of Aged Care Online Claiming after that date. These
terms and conditions may not be otherwise changed orally or
by conduct by me
e) I must ensure that my agents do not do anything that these
terms and conditions prevent me from doing
AC004.1307 (formerly 2505)
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Declaration
18I agree to:
• conduct transactions electronically with the Department of
Human Services using Aged Care Online Claiming, and
• the Terms and Conditions set out in question 17.
I understand that:
• giving false and misleading information is a serious offence.
I declare that:
• as key personnel I have the authority to sign this document
• the information provided in this form is complete and correct,
and
• I have read and understood the Terms and Conditions as
outlined in question 17.
Authorised person’s full name
Authorised person’s signature
Date
/
/
Reset form
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Privacy notice
Centrelink, Medicare, Child Support and CRS Australia are services
within the Australian Government Department of Human Services
(Human Services).
Your personal information is protected by law, including the
Privacy Act 1988. Your information is collected for Social Security,
Family Assistance, Medicare, Child Support and CRS purposes. This
information may be required by the powers provided within each
services’ legislation or voluntarily given by you when you apply for
services or payments.
Your information will be used for the assessment and administration
of payments and services. Your information may also be used within
Human Services, where you have provided consent or it is required or
authorised by law. Human Services may disclose your information to
Commonwealth Departments, other persons, bodies or agencies ONLY
where you have provided consent or it is required or authorised by law.
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full
privacy policy at any of our Service Centres.
AC004.1307 (formerly 2505)
www.
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