Instructions
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My Aged Care
Appointment of a Support Person Form
When to use this form Protecting you and
For more information
your information
This form is to appoint a support Your personal information, and your To talk to someone from
person to help you access support person's, is protected by law, My Aged Care about this form:
My Aged Care services. including the Privacy Act 1988 and
the Australian Privacy Principles. • Call My Aged Care on
If you want to access government 1800 200 422
subsidised aged care services, you Monday to Friday, between
Your personal information is
need to register with My Aged 8:00am and 8:00pm, and
collected by My Aged Care,
Care. To do this you can either call Saturday, between 10:00am
government funded service providers
My Aged Care yourself or someone and 2:00pm.
and assessors for the assessment
else (a 'representative' or 'agent')
and provision of government funded • In person with an Aged Care
can talk to My Aged Care with you.
aged care services. Specialist Officer (ACSO).
You can also register online as part Make an appointment by
of the assessment application More information about how calling 1800 227 475 on
process at: My Aged Care looks after your weekdays from 8am to 8pm.
https://myagedcare.gov.au. personal information can be found at: You can visit the
https://www.myagedcare.gov.au/ Services Australia website for
A support person set up with this privacy more information on the latest
form is limited to accessing ACSO locations.
information and interacting with You may also visit the My Aged Care
My Aged Care. These website for more information at:
arrangements do not extend to https://www.myagedcare.gov.au/
other government agencies.
arranging-someone-support-you
What is a Support Person in My Aged Care?
A Support Person is able to provide you with assistance in accessing services and support in My Aged Care. They
could be a family member, a friend, a carer or someone who provides support within a community. Some support
people may also be legally appointed. By entering into a Support Person relationship the information and
discussions are limited to the client and nominated individual, this means no other person may act or access your
My Aged Care information unless a relationship has been consented to.
There are three types of support relationships that you can have in My Aged Care:
Regular representative
A regular representative is able to support you and be involved in discussions with My Aged Care, access and
update all of your information and convey decisions to My Aged Care with your consent.
Authorised representative
If you are not capable of providing consent for someone to become an Agent or Regular Representative, an
authorised representative can be legally appointed to act on your behalf and make My Aged Care decisions for you.
Agent
An agent is able to support you, be involved in discussions with you, access and update some of your
information, but can't make decisions about your care or services when liaising with My Aged Care. They will be
a professional, such as a cultural support person who provides support within a community, who is not affiliated
with an approved support organisation.
The table on Page 7 at the end of this form provides further detail about the actions that can be completed for you
by a support person.
Page 1 of 7
THIS FORM IS FOR APPOINTING AN INDIVIDUAL SUPPORT PERSON
How to complete this form
You can complete this form on your computer or print and sign.
PART A – your (the client's) details (the person requesting an agent, regular or authorised representative).
PART B – the nominated support person’s details.
PART C, D or E – the relationship details, your (the client's) consent and the support person's consent to the
relationship.
Complete one of parts C, D, and E only, according to the support relationship being created.
How to submit this form
After completing and signing the form according to the instructions above, send it to My Aged Care:
1. Upload to your Online Account (more information on how to access your Online Account is available on the
My Aged Care website at: https://www.myagedcare.gov.au/access-your-online-account#mygov-login) or
2. Send a digital copy via the My Aged Care online form available at:
https://www.healthdirect.gov.au/myagedcareupload or
3. Mail to:
My Aged Care,
PO Box 1237,
Runaway Bay,
Queensland, 4216 or
4.In person by visiting a Services Australia centre where a General Service Officer can help you submit
documents to My Aged Care or book an appointment with an Aged Care Specialist Officer who can upload
the documents to My Aged Care. You can call Services Australia on 1800 227 475 to book a face-to-face
appointment.
For authorised representatives, please make sure you have attached relevant legal documents before returning this
form.
If you want to check that My Aged Care has received your form, please wait before calling (two business days for
upload, six business days for mail).
Next Steps after submitting to My Aged Care
When My Aged Care receives your completed form, they will register both you and your support person with
My Aged Care if required, and call your support person if they need extra information to process the form.
Once your support arrangement has been put in place, the nominated person can call My Aged Care on
1800 200 422 to discuss your aged care assessments and services.
Further information if you would like an organisation to support you
If you would like staff at an organisation to support you with My Aged Care, such as an advocacy organisation, you
can request an organisation relationship with an organisation that has been approved by the Department of Health
and Aged Care to provide assistance to My Aged Care clients.
The form to nominate a support organisation is available at:
https://www.myagedcare.gov.au/publications/appointment-support-organisation-form
You can view a list of the approved support organisations at:
https://www.myagedcare.gov.au/arranging-someone-support-you
Page 2 of 7
THIS FORM IS FOR APPOINTING AN INDIVIDUAL SUPPORT PERSON
PART A - Aged Care Client Details (Your details)
You must complete all fields marked with an asterisk (*)
Title (select one):* Date of Birth* Phone Number*
Mr Mrs Miss Ms
Dr Other Home address Line 1*
Last name*
Home address Line 2
First name*
State/Territory* Postcode*
Middle name
Medicare Card # (including Individual
Preferred name Reference Number) or DVA card #*
Gender (select one):*
Male Female Aged Care (AC) ID (if known)
Indeterminate/Intersex/Unspecified
Not Specified
What type of support is required (select one)?* Does the client have capacity to provide
consent to establish this representation
Support to make decisions (Agent) (select one)?*
Complete PART B and PART E Yes (Regular Representative)
Complete PART B and PART C
Make decisions about care (Representative)
Go to NEXT QUESTION No (Authorised Representative)
Complete PART B and PART D
PART B – Support Person's Details
You must complete all fields marked with an asterisk (*)
Title (select one):* Home address 1*
Mr Mrs Miss Ms
Dr Other
Home address 2
Last name*
First name* State/Territory* Postcode*
Middle name Medicare Card # (including Individual
Reference Number) or DVA card # (optional)
Preferred name
Relationship to Client (select from the drop
down menu):
Gender (select one):*
Male Female Please select one
Indeterminate/Intersex/Unspecified Scope of Representative Authority (if
Not Specified Representative)1
Date of Birth* Phone number* Select from the drop down menu:
Please select one
1
Note: 'Care' decisions (decisions about a client's care or preferences) are the only decisions applicable to My Aged Care. Page 3 of 7
If you only have financial decision-making authority, a My Aged Care authorised representative relationship cannot
be established.
THIS FORM IS FOR APPOINTING AN INDIVIDUAL SUPPORT PERSON
PART C – Appointing a regular representative
Please complete all fields if you are appointing a regular representative. A regular representative can support you and
be involved in discussions regarding My Aged Care and convey decisions to My Aged Care.
Aged Care Client’s Consent and Declaration Representative’s Consent and Declaration
I consent to my nominated representative As the Aged Care Client's representative, I
accessing my information in My Aged Care in consent to represent them in My Aged Care, and
order to act on my behalf as my representative. acknowledge the representative declaration below.
I declare that: I declare that:
• I am voluntarily appointing a representative. • Any information I provide to My Aged Care about
• The information I have provided in this form is myself or the person being represented is complete
complete and correct. and correct.
• Any information I obtain from My Aged Care will be
I authorise My Aged Care, including kept confidential and will not be disclosed to any
Commonwealth funded service providers and unauthorised person without the permission of the
assessors to: person making this appointment.
• Collect information about me from my • Any decisions made on behalf of the person I
representative. represent will be made in consultation with the
• Discuss my progress in My Aged Care with my person being represented.
representative. • I will work and consult with other representatives (if
• Take action in response to decisions my applicable) of the represented person and any
representative has made in consultation with me. decisions made on behalf of the person being
I understand that: represented will be in their interests.
• This appointment is specific to interactions with My I understand that:
Aged Care. • This appointment is specific to interactions with My
• My representative may receive correspondence Aged Care.
about me from My Aged Care. • This arrangement can be cancelled at any time by
• I can cancel this arrangement at any time by calling calling My Aged Care on 1800 200 422, through my
My Aged Care on 1800 200 422, through my Online Online Account or Portal, or with an Aged Care
Account or with an Aged Care Specialist Officer. Specialist Officer.
• Giving false or misleading information is a serious • My Aged Care must be informed of any changes to
offence. my address and contact details, and changes in the
• If I do not already have a record in My Aged Care, circumstances of the person who has made the
making this appointment will create one for me. appointment.
• Giving false or misleading information is a serious
When will the relationship start (DD/MM/YYYY)? offence.
• I will receive correspondence on behalf of the Aged
Care client being represented.
When will this relationship end (DD/MM/YYYY or • Making this appointment will create a record for me
leave blank if no end date)? in My Aged Care, if I don't already have one.
Aged Care Client's full name Representative's full name
Aged Care Client's signature Representative's signature
Date Signed Date Signed
Page 5 of 7
THIS FORM IS FOR APPOINTING AN INDIVIDUAL SUPPORT PERSON
PART D – Appointment of an authorised representative
Please complete all fields if you have the appropriate legal and supporting documentation to act on the client's
behalf and make My Aged Care decisions on their behalf.
To become an authorised representative in Representative’s Consent and Declaration
My Aged Care, legal documents are required to show I consent to represent the Aged Care Client in
that you have been legally authorised to make health, My Aged Care, and acknowledge the representative
personal and/or lifestyle decisions for a client. If you declaration below.
only have financial decision-making authority, a I declare that:
My Aged Care authorised representative relationship • Any information I provide to My Aged Care about
cannot be established. myself or the person I represent is complete and
The legal documents needed to become an authorised correct.
representative are determined by your state or territory • Any information I obtain from My Aged Care will be
legislation. A guide to what documents are accepted kept confidential and will not be disclosed to any
by My Aged Care is outlined below and available on unauthorised person.
the My Aged Care website at: • I will act in accordance with the conditions contained
https://www.myagedcare.gov.au/legal-information/ within the legal documentation that outlines the legal
powers-attorney-enduring-powers-attorney-and- authority with respect to the person being
enduring-guardians. represented.
• I will work with and consult other representatives (if
If your legal representation changes after you become applicable) of the represented person and any
an authorised representative or the person you are decisions made on behalf of the person being
representing no longer needs an authorised represented will be in their interests.
representative, you must call My Aged Care on 1800 I understand that:
200 422 to cancel this appointment or become an • Making this appointment will create a record for the
agent or regular representative. person being represented in My Aged Care, if they
don't already have one.
Which of the following forms of legal authority do
• This appointment is specific to interactions with
you hold on behalf of the My Aged Care Client?
My Aged Care.
(only select one)*
• As the Primary Contact, I will be the first point of
Enduring Guardianship and a letter from a telephone contact for My Aged Care for the person
Medical Practitioner that states the client being represented.
cannot act on their own behalf • This arrangement can be cancelled at any time by
calling My Aged Care on 1800 200 422, through my
Guardianship Order
Online Account or Portal, or with an Aged Care
Enduring Power of Attorney (ACT, QLD and
Specialist Officer.
VIC only) and a letter from a Medical
• My Aged Care must be informed of any changes to my
Practitioner that states the client cannot act on
address and contact details, and changes in the
their own behalf circumstances of the person who has made the
Advance Health Directive (ACT and WA not appointment.
included) or similar and a letter from Medical • My Aged Care must be informed if I are no longer a
Practitioner that states the client cannot act on legal representative for this Aged Care Client.
their own behalf. • Giving false or misleading information is a serious
Other (e.g. statutory declaration) offence.
• I will receive correspondence on behalf of the Aged
Attach a copy of the relevant authorisation(s). Care Client being represented.
Note: The document must state that you have been legally
authorised to make health, personal and/or lifestyle decisions
for someone.
Representative's full name
When will the relationship start (DD/MM/YYYY)?
Representative's signature
When will this relationship end (DD/MM/YYYY or
leave blank if no end date)? Date Signed
Page 6 of 7
THIS FORM IS FOR APPOINTING AN INDIVIDUAL SUPPORT PERSON
PART E – Appointing an agent
Please complete all fields if you are appointing an agent. An agent can support you, be involved in discussions with
you, but can’t make decisions for you regarding My Aged Care.
Aged Care Client Consent and Declaration Agent’s Consent and Declaration
I consent to my nominated agent accessing my As the Aged Care Client’s appointed agent, I consent
information in My Aged Care in order to assist me to to accessing their information in My Aged Care in order
make decisions as my agent. to assist them as their agent, and acknowledge the
agent declaration below.
I declare that:
• I am voluntarily appointing an agent. I declare that:
• The information I have provided in this form • Any information I provide to My Aged Care about
is complete and correct. myself, staff, the organisation, or the person being
I authorise My Aged Care, including assisted is complete and correct.
Commonwealth funded service providers and • Any information I obtain from My Aged Care will be
assessors to: kept confidential and will not be disclosed to any
• Collect information about me from my agent. unauthorised person without the permission of the
• Discuss my progress in My Aged Care with my person making this appointment.
agent. I understand that:
I understand that: • This appointment is specific to interactions with My
• This appointment is specific to interactions with My Aged Care.
Aged Care. • This arrangement can be cancelled at any time by
• My agent may receive correspondence about me calling My Aged Care on 1800 200 422, through my
from My Aged Care. Online Account or Portal, or with an Aged Care
• I can cancel this arrangement at any time by calling Specialist Officer.
My Aged Care on 1800 200 422, through my Online • My Aged Care must be informed of any changes to
Account or with an Aged Care Specialist Officer. my address and contact details, and changes in the
• Giving false or misleading information is a serious circumstances of the person who has appointed
offence. me.
• If I do not already have a record in My Aged Care, • Giving false or misleading information is a serious
making this appointment will create one for me. offence.
• I may receive correspondence on behalf of the
When will the relationship start (DD/MM/YYYY)? Aged Care Client being assisted.
• Making this appointment will create a record
for me in My Aged Care, if I don't already have
When will this relationship end (DD/MM/YYYY or one.
leave blank if no end date)?
Aged Care Client's full name Agent's full name
Aged Care Client's signature Agent’s organisation name
Date Signed Agent’s signature
Date signed
Page 4 of 7
Actions available to a support person in My Aged Care
Regular Authorised Agent
A nominated support person can:
Representative Representative
Give information to My Aged Care including talking to assessors,
the My Aged Care contact centre and service providers
Request information about the your progress in My Aged Care
Submit an ‘Apply for Assessment Online’ on your behalf
Access client record information except assessment detail*
through the contact centre or in the My Aged Care Online Account
via myGov
Only able to update your contact and service preference
information^ through the My Aged Care contact centre or the
My Aged Care Online Account
Access all client record information including assessment
detail through the contact centre or in the My Aged Care
Online Account via myGov
Update all your information through the contact centre or in
the My Aged Care Online Account via myGov
Be nominated as your first contact point for My Aged Care
phone calls (Primary Contact)
Receive email notifications and copies of correspondence, for
example, Home Care Package letters
Upload documents on your behalf within My Aged Care
Provide consent and convey decisions to My Aged Care on your
behalf, with your consent e.g. to commence screening, generate a
referral code, request a support plan review
Make decisions on the your behalf and provide consent to
commence an aged care assessment (and complete the
My Aged Care assessment consent form), support plan
review and send referrals for aged care services
*Agents can view most information in your record (current care approvals, current services and service recommendations, people associated with the care
plan, review history, and reablement and linking support history), but cannot view your assessment history or view/print the National Screening and
Assessment Form (NSAF).
^Agents can edit your contact details (phone, address, primary contact), generate a referral code, and set your seeking services preference to ‘Yes’. They
cannot set your seeking services preference to ‘No’ or decline a home care package.
*Note: For Agents and Regular Representatives it is 'Optional' to be a Primary Contact and/or receive notifications. Page 7 of 7
