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Nominee Appointment Form

Nominee Appointment form for residential aged care recipients.

The Department of Health and Ageing has produced a new Nominee Appointment form. This form should be used by residents in Commonwealth funded Aged Care facilities who wish to authorise another person to deal with the Department on their behalf. This form should also be used for residents who are mentally impaired and therefore unable to administer their own affairs.

If you are in residential aged care, you may authorise another person (a 'nominee') to deal with the Australian Government Department of Health and Ageing ('the Department') on your behalf. The nominee may receive information from the Department about your care costs and may give the Department information about your income and assets. If you decide not to appoint a nominee, the Department will contact you directly about these matters. You may vary or cancel the appointment of a nominee at any time, by writing to the Department.

You may download this document in PDF format:

PDF printable version of the Appointment of a Nominee Form (PDF 119 KB)

Need help? Call the Aged Care Information Line on 1800 200 422.

If you are unable to download the PDF file please send an email to: acc@health.gov.au for a copy to be sent to you.

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The following text representation of the Appointment of a Nominee form is available for reading purposes only.

If you are in residential aged care, you may authorise another person (a ‘nominee’) to deal with the Australian Government Department of Health and Ageing (‘the Department’) on your behalf. The nominee may receive information from the Department about your care costs and may give the Department information about your income and assets. If you decide not to appoint a nominee, the Department will contact you directly about these matters. You may vary or cancel the appointment of a nominee at any time, by writing to the Department. Please note: if your nominee does not hold a Power of Attorney or similar, both you and your nominee will receive letters from the Department.

Please mail the completed form to Aged Care Medicare Australia** in your State/Territory

NSW, QLD, WA and ACT

GPO Box 9923
SYDNEY NSW 2001

VIC,SA, TAS and NT

GPO Box 9923
MELBOURNE VIC 3001

**Providing aged care payments to service providers on behalf of the Department.

Part A – Resident’s personal details

Resident’s family name

Mrs/Mr/Ms/Miss

Date of birth / /

Given names

Department Reference Number (if known)

Name of Aged Care Home

Phone number ( )

Address of Aged Care Home

Postcode

1. Is the resident mentally impaired and cannot complete this form?

Yes Go to Part D

No Answer Question 2

2. Is the resident physically impaired and cannot complete this form?

Yes Go to Part C

No Go to Part B
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Part B - To be completed when the resident is without physical or mental impairment

a) Declaration - Resident

• I certify that I am voluntarily appointing a nominee.
• I authorise the Department to discuss my care costs, income and assets with my nominee.
• I authorise the Department to send letters about my care costs to my nominee.

• I understand that I can cancel this appointment at any time, by writing to the Department.

Signature of resident

Date / /

b) Nominee’s personal details

Family name

Mrs/Mr/Ms/Miss/Dr (etc)

Given names

Phone number (day time) ( )

Postal address

Postcode

c) Declaration - Nominee

• I certify that any information I obtain from the Department or Medicare Australia will be kept confidential and will not be disclosed to any unauthorised person without permission of the person appointing me.
• I understand that I can cancel this appointment at any time, by writing to the Department.
• I understand that I must inform the Department of any changes to my address and contact details, and changes in the circumstances of the person who has appointed me.

Signature of nominee

Date / /

Please indicate if you hold any of the following forms of authorisation on behalf of the resident.
enduring power of attorney
guardianship order
financial management/administration order
appointment of enduring guardian

If so, please attach a copy of the relevant authorisation.
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Part C - To be completed when the resident is so physically impaired that they cannot complete this form

a) Nominee’s personal details

Family name

Mrs/Mr/Ms/Miss/Dr (etc)

Given names

Phone number (day time) ( )

Postal address

Postcode

b) Please indicate if you hold any of the following forms of authoriation on behalf of the resident:

enduring power of attorney
guardianship order
financial management/administration order
appointment of enduring guardian

If so, please attach a copy of the relevant authorisation.

c) Declaration - Nominee

• I certify that any information I obtain from the Department or Medicare Australia will be kept confidential and will not be disclosed to any unauthorised person without permission of the person appointing me.
• I understand that I can cancel this appointment at any time, by writing to the Department.
• I understand that I must inform the Department of any changes to my address and contact details, and changes in the circumstances of the person who has appointed me.

Signature of nominee

Date / /
Please note: If you hold one of the forms of authorisation at (b) above, the resident declaration below is not required.

d) Declaration - Resident

• I certify that I am voluntarily appointing a nominee.
• I authorise the Department to discuss my care costs, income and assets with my nominee.
• I authorise the Department to send letters about my care costs to my nominee.

• I understand that I can cancel this appointment at any time, by writing to the Department.

Signed at the direction of the resident by the
Director of Nursing/Hostel Manager/Care Manager

Date / /

Name

Position
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Part D - To be completed when the resident is so mentally impaired that they cannot complete this form

a) Nominee’s personal details

Family name

Mrs/Mr/Ms/Miss/Dr (etc.)

Given names

Phone number (day time) ( )

Postal address

Postcode

To be appointed the nominee of a mentally impaired resident, you must be authorised to do so:

b) Do you have any of the following forms of authorisation to act on the resident’s behalf?

enduring power of attorney
guardianship order
financial management/administration order
appointment of enduring guardian

If so, please attach a copy of the relevant authorisation

c) If you do not have one of the above forms of authorisation, are you the spouse/partner of the resident?

Yes

No

d) Declaration - Nominee

• I certify that any information I obtain from the Department or Medicare Australia will be kept confidential and will not be disclosed to any unauthorised person.
• I understand that I can cancel this appointment at any time, by writing to the Department.
• I understand that I must inform the Department of any changes to my address and contact details, and changes in the circumstances of the person for whom I am acting.

Signature of nominee
Date / /
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