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) / 2 of 6 / 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) / / 3 of 6 / 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) 5 of 6 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 Print form 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. 6 of 6
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