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Home Care Service Notification Form
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Home Care Service Notification Form
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Cover Page

Home Care Service Notification Form
Fields marked with * are required
This form enables approved providers for home care to notify the Secretary of new or changes in home care services through which it proposes to provide home care under the Aged Care Act 1997 (the Act) and Amendment Act.
Before completing this form, your organisation must be an approved provider of home care services under the Act.
About this form
As required by section 9-1A of the Amendment Act, this form serves as a means of notification to the Secretary, that must be made before an approved provider can provide home care through a home care service. Providing home care service information is a precondition towards your organisation’s ability to claim and receive subsidies for the provision of home care through a new home care service.
Please ensure a separate form is submitted for each home care service from which you intend to provide home care before you commence providing care through that service. This form should also be used to notify the Secretary of any changes in name or address of existing home care services. As an approved provider your organisation must notify the Secretary of any changes in name or address within 28 days as required by section 9-1A of the Act.Existing home care services need not submit this form unless there is a change in the name or address of the service.If your organisation does not comply with obligations under section 9-1A of the Amendment Act and the Aged Care Act the department may take compliance action.The information collected in this application is protected information as defined under section 86-1 of the Act. You can access the Department of Health (the Department) privacy policy at www.health.gov.au.
How to use the form
•Use the Tab Key on your computer to move between fields marked “Click here to enter text”. •Use the Mouse to change the status on a check box or to “Choose an Item”. •Provide accurate, clear and complete information regarding the home care service.

Organisation Details

Home Care Service Notification Form
Fields marked with * are required

Organisation Details

Service Details

Home Care Service Notification Form
Fields marked with * are required

Is this an existing home care service? *

Physical Address of the Service

Address Validated
Address NOT Validated

Postal Address of the Service

Address Validated
Address NOT Validated

Authorised Contact Person

Authorised Contact Person

Review

Home Care Service Notification Form
Fields marked with * are required
Please review your answers before submitting your application. Note: You must return to the question screen in order to update any answers.

Organisation Details

Approved Provider Name:
Approved Provider ID:

Service Details

Is this an existing home care service?
Service Name:
Service ID (If known):
Service Start Date:
Service End Date (If applicable):

Physical Address

Floor / Building; Unit; Apartment:
Street number, name and type:
Suburb / Town:
State:
Postcode:

Postal Address

Floor / Building; Unit; Apartment:
Street number, name and type:
Suburb / Town:
State:
Postcode:

Authorised Contact Person/s


Authorised Contact Person
Primary:
Name:
Position:
Purpose:
Phone number:
Fax:
Mobile number:
Email address:
Web address:
Best day and time to make contact:
Preferred contact method:

Endorsement and Declaration

Home Care Service Notification Form
Fields marked with * are required
The person signing Section 3 of the Home Care Service Notification Form must be an authorised representative and someone who is legally authorised to give assurances and enter into contracts and commitments on behalf of the organisation.ENDORSEMENT:•This endorsement covers all information provided in the form and must be signed by those persons who are legally empowered to give assurances and enter into contracts and commitments on behalf of the organisation.DECLARATION:•I/we understand that the Criminal Code applies to offences against the Act and that providing false or misleading information in this notification is a serious offence.

AuthorisingOfficer

Next Steps

Before you submit the form, check that you have completed all the responses. You will be unable to submit the form if mandatory questions are incomplete. After you submit the application, you will receive an email with the tracking Id and a pdf version of the completed form. No further access to this form is possible after it has been submitted.You will be notified once the information has been processed following which administrators will be able to set up ‘Outlets’ in the provider portal and add the organisation’s service information (service items and service sub-types).The Department may contact you if further information is required.If you have any queries, please send an email with your name and contact details to the appropriate mailbox based on the state you intend to providing services in.NSW / ACT - NSWPlaces@health.gov.auVIC - VICPlaces@health.gov.auQLD - QLDPlaces@health.gov.auNT - NTPlaces@health.gov.auSA - SAPlaces@health.gov.auWA - WAPlaces@health.gov.auTAS - TASPlaces@health.gov.au
YOUR DEPARTMENT NAME HERE