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Pennwood Village
Pennwood Kings Park
Fees & Charges
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About Us
Pennwood Village
Pennwood Kings Park
Fees & Charges
Join Our Team
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(08) 8341 0401
Home Care
Pennwood Home Care
Home Care Services
Fees & Charges
Residential Care
Pennwood Residential Care
Fees & Charges
Respite
Transition Care Program(TCP)
Penwood Transition Care Program (TCP)
TCP Goals
TCP Referrals
Home Care
Pennwood Home Care
Home Care Services
Fees & Charges
Residential Care
Pennwood Residential Care
Fees & Charges
Respite
Transition Care Program(TCP)
Penwood Transition Care Program (TCP)
TCP Goals
TCP Referrals
Contact us
Residential Aged Care Application Form
Application Type
Application Type
Select application type
Permanent
Respite Care
Permanent
Timeframe
*
Select timeframe
Now
Within 1 month
1 - 3 months
3 - 6 months
Longer
MAC Referral Code
*
12-digit code
0 / 13
Select Dates
Date From
Date To
MAC Referral Code
*
12-digit code
0 / 13
Advance Health Directive in place?
Yes
No
Please attach a copy
Choose File
No file chosen
Delete uploaded file
Upload files
Drag and Drop (or)
Choose Files
Please provide Pennwood with a copy of your current Residential Care Agreement, DHS / DVA fees letter and recent Invoice
Transfer From other ACR Provider?
Yes
No
ACR Details
Name
Date of Entry
Applicant Details
Applicant Name
Title
Mr.
Mrs.
Miss.
Other
Choose not to say
Please specify (Other)
Given Name/s
Last Name
Preferred Name
Date of Birth
Country of Birth
Nationality
Religion
Preferred Language
Cultural Background
E.g. Serbian
Marital Status
Married
Widowed
Single
Separated
Divorced
De Facto
Mobile
*
E.g. 0412345678
Home Phone
E.g. (08)83410401
Email Address
E.g. john@doe.com
Current Location
E.g. 42 Wallaby Way
ZIP / Postal Code
*
E.g. 5000
HEALTH CARE DETAILS
Pension/Concession: (If applicable)
DSS
DVA
NB: A copy of this card will be required on admission
Expiry Date
Medicare
NB: A copy of this card will be required on admission
0 / 20
Expiry Date
*
Individual Reference Number (IRN)
If more than 1 person is listed on the medicare card
NDIS
Are you currently on an NDIS Plan?
*
Yes
No
Plan Managed By
Self Managed
Plan Managed
Agency Managed
Provider Name
E.g. John Doe
Contact Email
E.g. john@doe.com
NOMINATED REPRESENTATIVE DETAILS
First Contact
Title
Mr.
Mrs.
Miss.
Other
Choose not to say
Other
Given Name/s
Last Name
Mobile
*
E.g. 0412345678
Email Address
E.g. john@doe.com
Current Location
E.g. 42 Wallaby Way
ZIP / Postal Code
E.g. 5000
Relationship to Resident (Please tick all that apply)
*
Spouse
Son
Daughter
Parent
Brother
Sister
Friend
Emergency Contact
Account Contact
Power of Attorney
Executor of Will
SACAT appointed guardian
SACAT appointed administrator
SACAT applicant
Other
Please specify
Second Contact
Title
Mr.
Mrs.
Miss.
Other
Choose not to say
Other
Given Name/s
Last Name
Mobile
E.g. 0412345678
Email Address
E.g. john@doe.com
Current Location
E.g. 42 Wallaby Way
ZIP / Postal Code
E.g. 5000
Relationship to Resident (Please tick all that apply)
Spouse
Son
Daughter
Parent
Brother
Sister
Friend
Emergency Contact
Account Contact
Power of Attorney
Executor of Will
SACAT appointed guardian
SACAT appointed administrator
SACAT applicant
Other
Please specify
Account Contact Details
Please advise the details of where the accounts should be sent.
Name
Phone
E.g. (08)83410401, 0412345678
Email Address
Residents who do not provide an email account contact will be charged a $2 administration fee per statement.
Street Address
FINANCIAL ADVICE / ASSESSMENT
Permanent Residents Only
A. Have you engaged the services of a Financial Advisor?
Yes
No
Firm/Name
Phone
E.g. (08)83410401, 0412345678
B. Have you submitted a Centrelink/DVA Income & Asset Assessment?
Select an option
Yes, lodged or to be lodged and waiting for Centrelink/DVA Statement, or
Yes, documentation enclosed with this application.
No, I do not wish to disclose my Assets. I understand that I will be charged the maximum fees and charges as determined by the Department of Human Services (Centrelink).
For further information please call the Finance Team on 08 8341 0401
Lodgement Date
Date the assessment lodged or to be lodged on
DETAILS OF EXECUTOR OF WILL
Please advise the details of the executor of your will.
Name
Street Address
Phone
E.g. (08)83410401, 0412345678
Email Address
PENSION / INCOME
Do you receive a full or part pension from Centrelink or DVA or other income support payment?
Select an option
Yes, I receive an Australian pension
Yes, I receive an Overseas pension - Country
No, I am financially independent and do not receive any pension
Please Specify
Centrelink
Department of Veteran Affairs
Full Pension
Part Pension
Age
Disability
Widow
Blind
Other
Other
1. Do you own or partly own the property in which you normally live?
No
Yes
Value $
2. Do you have a partner or dependent child living in your home?
No
Partner /Dependent
3. Do you own, or partly own any other residential or commercial property?
No
Yes
Value $
4. Have you any property or personal loans to repay
No
Yes
Amount $
5. Have you gifted more than $10k per annum or $30k total within the last 5 years?
No
Yes
6. Do you have more than $51,500 in bank accounts, shares or superannuation?
No
Yes
Amount $
Submit Application
Search
Search
Services
Home Care
Residential Care
Respite
Transition Care Program(TCP)
Pennwood Village
Fees & Charges
About Us
Join our team
Contact us
Services
Home Care
Residential Care
Respite
Transition Care Program(TCP)
Pennwood Village
Fees & Charges
About Us
Join our team
Contact us
(08) 8341 0401
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