PLEASE COMPLETE ALL QUESTIONS IN THIS FORM
If the answer is unknown either enter “Unknown” or “Not Applicable” in the space provided
PERSON RESPONSIBLE & FAMILY DETAILS PERSON RESPONSIBLE
Where a resident is at any stage unable to give directions or necessary consents to medical and other care, the Home may obtain such directions
and consents from the ‘person responsible’ for the resident. A ‘person responsible’ is not necessarily the resident’s next of kin. A ‘person
responsible’ is either:
- A guardian who has the function of consenting to medical, dental and health care treatments or, if there is no guardian;
- A spouse or de facto spouse with whom the person has a close, continuing relationship or, if there is no spouse or de facto spouse;
- An unpaid carer who is now providing support to the person or provided this support before the person entered residential care; or
- If there is no carer:
- A relative or friend who has a close personal relationship with the person.
Who would be your ‘Person Responsible’?
IN THE EVENT OF EMERGENCY PLEASE CONTACT
(an emergency is a significant change in the resident’s medical condition)
POWER OF ATTORNEY / FINANCIAL MANAGER
A person can appoint another person Power of Attorney to execute documents and conduct financial and property matters on their behalf. Alternatively,
a formal Financial Manager can be appointed by the Guardianship Tribunal.
Do you have a signed document for:
GUARDIAN OR ENDURING GUARDIAN / ADVANCED CARE DIRECTIVE (LIVING WILL) OR TREATMENT PLAN
A person can appoint a Guardian or Enduring Guardian to make decisions in relation to accommodation and medical and other care should that
person be unable to do so. Alternatively, a Guardian can be appointed by the Guardianship Tribunal.
Do you have a signed document for a:
Please complete if you have pre – arranged funeral arrangements you would like the facility to follow in the event of death:
DETAILS OF NEXT OF KIN (A PERSON’S CLOSEST LIVING BLOOD RELATIVE OR RELATIVE BY MARRIAGE / FAMILY).
(If insufficient space, please attach separate list)
(if same as ‘person responsible’ write “as above”) - add tickbox copy
Children/ Significant Persons
CURRENT RESIDENTIAL AGED CARE FACILITY
Dubbo RSL Aged Care Association is a “smoke free” environment. Therefore, no resident is permitted to smoke within the confines of the entire
facility except in designated smoking areas outside the building.
Residential aged care fees and charges are strictly regulated by the Commonwealth Government and can vary depending on your financial circumstances.
Information regarding your income and assets are required by the Admissions Department in order to determine the appropriate level of fees
and charges to apply to your residency. For further information regarding Admissions Fees & Charges please refer to the ‘Residents
Handbook’ enclosed in the Admissions Pack.
For the purposes of your residence (or proposed residence) at the Home and the services we provide to you, we will need to collect, record and use personal information about you (including medical and financial information).
We may also sometimes need to disclose some of that information to:
1. Appropriate organisations, such as government departments (in Australia and, for some residents, in other countries), hospitals and other homes or hostels to which you may seek to move, and/or
2. Medical practitioners, other health service providers, professional advisers and other appropriate persons, such as guardians or other persons responsible under the Guardianship Act NSW (1987).
In considering any disclosure to be made, we will bear in mind the maintenance of your privacy as an important criterion, subject to our need to perform our obligations and services.
By submitting this form, you signify your consent to our collecting, recording, using and disclosing, as we consider appropriate from time to time, personal information in relation to yourself. If you wish to limit any disclosure we may make, would you please delete “Nil” below and specify the limitations you require. Absence of consent may not necessarily preclude the Home from collecting, recording, using or disclosing such information.
By submitting this Application you declare that the information given in this form is true and complete, you give the undertaking set out above in relation to change to any Power of Attorney and/or appointment of Guardian or Financial Manager and you provide the privacy consent set out above.