Continence Aids Payment Scheme
Application Form

Continence Aids Payment Scheme
Application Form

Medicare records

A Centrelink Correspondence Nominee, a DVA Trustee or a responsible person authorised by the Secretary of the Department is able to update information about the applicant for the purposes of CAPS and provide  bank details  for CAPS payments.  However,  they are not able to update the applicant’s Medicare record, including bank account details used by Medicare to make Medicare payments, or update the address details used by Medicare for Medicare-related  purposes.

Privacy and your personal information

Personal information  is protected by law, including by the Privacy Act 1988.
The information provided on this application will be stored and
used by Medicare for the purposes of making payments and issuing correspondence  for the CAPS program.
This information may also be used to update the applicant’s existing personal information held by Medicare.
The collection of this information is authorised by the Human
Services (Medicare) Act 1973.
The information may be disclosed to person/s or organisations authorised to receive payments and/or correspondence on behalf of the applicant, relevant fnancial institutions to facilitate payment, the Department of Health, other relevant government agencies or as authorised or required by law.

Change of circumstances

Medicare must be notifed if a CAPS participant ceases to be eligible for the CAPS payments. Medicare must also be notifed if a CAPS participant’s, or their representative’s, circumstances change. You can do this by calling Medicare on 132 011 select general enquiries (call charges may apply) between 9:00am and 5:00pm AEST

Assistance

If you need assistance completing this form call Medicare on
1800 239 309. For more information about the CAPS call the National Continence Helpline on 1800 330 066 or go to www.bladderbowel.gov.au

ELIGIBILITY GUIDE

To be eligible  for the CAPS an applicant  must be five years of age or older and meet one of the following requirements:

A	have permanent and severe loss of bladder and/or
	bowel function (incontinence) due directly to an 			eligible neurological condition; OR
B	have permanent and severe loss of bladder and/or bowel 			function (incontinence) caused by an eligible other 				condition, provided the applicant has a Centrelink or DVA 			Pensioner Concession Card or entitlement, whether  as 				primary cardholder or a dependant of a cardholder.

 
Responses to the five questions below will further indicate
whether  the applicant  is eligible  for the CAPS. Please refer to       CAPS application guidelines. The following questions must be    answered.

E1	Is the applicant an Australian Citizen?

	Yes	q	No	q

 E2	Is the applicant a permanent Australian Resident?

	Yes	q	No	q

E3	Is the applicant a permanent high care resident in an
	Australian Government funded aged care home?

	Yes	q	No	q
 
If the answer is Yes, then the applicant is not eligible for assistance from CAPS. Refer to CAPS application guidelines.	

E4	Does the applicant receive an Australian Government 		funded Home Care Package and continence products
              are negotiated as part of the applicant's care plan?

	Yes	q	No	q

If the answer is Yes, then the applicant is not eligible for assistance from CAPS. Refer to CAPS application guidelines.	

E5	Is the applicant eligible to receive assistance with 			continence products from the Department of Veterans 		Affairs Rehabilitation Appliance  Program (RAP)?

	Yes	q	No	q

If the answer is Yes, then the applicant is not eligible for assistance from CAPS. Refer to CAPS application guidelines.	

E6	Does the applicant receive funding from the Australian                     Government National Disability Insurance Scheme and                    continence products are negotiated as part of the                             applicant's plan.

	Yes	q	No	q

If the answer is Yes, then the applicant is not eligible for assistance from CAPS. Refer to CAPS application guidelines.	

	
	                 Continence Aids Payment Scheme Application Form  2 	

SECTION 1 - APPLICANT DETAILS	

	

A1	
Medicare Card number	

 <<Patient Demographics:Medicare Number>>	

	

Ref No.   	

	

A2	
 <<Patient Demographics:Title>>	

 Family name (as recorded on the Medicare card)	

 <<Patient Demographics:Surname>>	

	

First given name	

 <<Patient Demographics:First Name>>	

	

A3	
 Date of Birth	

 <<Patient Demographics:DOB>>	

	

A4	
 Sex:  <<Patient Demographics:Sex>>	

	

A5	
 Home phone number	

 <<Patient Demographics:Phone (Home)>>	

	

 Work phone number (optional)	

  <<Patient Demographics:Phone (Work)>>	

	

 Mobile phone number (optional)	

 <<Patient Demographics:Phone (Mobile)>>	

	

Email address (optional)	

 <<Patient Demographics:E-mail>>	

	

A6	
Applicants residential address	

 <<Patient Demographics:Address Line 1>>	

 <<Patient Demographics:Address Line 2>>	

 <<Patient Demographics:City>>	

<<Patient Demographics:State>>   <<Patient Demographics:Postcode>>	

	

Applicants postal address	

 <<Patient Demographics:Address Postal Line 1>>	

 <<Patient Demographics:Address Postal Line 2>>	

 <<Patient Demographics:Address Postal City>>	

  <<Patient Demographics:State>>   <<Patient Demographics:Address Postal Postcode>>	

	

Medicare may update the applicant’s Medicare address if the person signing the declaration on this form is the applicant, the applicant’s parent or the applicant’s legal representative. Updating the Medicare card address will update the address of all persons listed on the Medicare card.	

	

	

	 
A7	
 Who will be signing the applicant declaration or
representative declaration section of this form 
(see Who can complete this form? on page 1)

	
	
  Applicant Go to A8		

	

	
	
  Applicant’s parent Go to A8	

	

	
	
  Applicant’s legal representative Go to A8	

	

	
	
  Other Go to A9	

A8	
Do you want the applicant’s Medicare card address to be updated with the address provided at question A6?	

Yes	q	No	q	

	

A9	
Is the applicant of Aboriginal, Torres Strait Islander or      South Sea Islander origin?	

	

	
 No	

	

	
	
 Yes - Aboriginal	

	

	
	
 Yes - Torres Strait Islander	

	

	
	
Yes - Australian South sea Islander	

	

A10	
 Where was the Applicant born	

	

	
 Australia	

	

	
	
 Other - Specify Country	

	
<<Patient Demographics:Country of Birth>>	

	

A11	
	
Does the applicant have a Centrelink or DVA Pensioner Concession Card (PCC), or is the applicant listed as a dependent on their parent or guardian’s PCC?	

	

	
 Yes - Go to A12	

	

	
	
 No -  Go to  A13	

	

A12	
	
Applicant’s Centrelink or DVA Number as recorded on the PCC.	

	
PCC:	
 <<Patient Demographics:Pension Number>>	

	

	
DVA:	
 <<Patient Demographics:DVA Number>>	

	

  Correspondence recipient

CAPS correspondence may be directed to a person other than the applicant, including to a family member or carer ofthe applicant. A correspondence recipient will receive all of the applicant’s CAPS correspondence, including the payment statement. If the applicant has a payment representative the payment representative will also receive a payment statement.	

                                                       question continues next page	
	
 Continence Aids Payment Scheme Application Form  3	

A13	
	
 Is a person other than the applicant to receive the
correspondence?	

	

	
 Yes - Go to A14	

	

	
	
 No -  Go to  A18	

	

A14	
	
Who is to receive the CAPS correspondence  on behalf of the applicant?	

	

	
 Applicant’s parent (applicant under 14 years of age)	

	

	
	
 Applicant’s parent (applicant 14 to 17 years of age)	

	

	
	
 Person appointed under a Power of Attorney	

	

	
	
  Person appointed under an enduring Power of 	

	
  Attorney	

	

	
	
  Appointed legal guardian	

	

	
	
  Centrelink Correspondence or Payment Nominee	

	

	
	
  DVA Trustee or Agent	

	

	
	
  Responsible person approved by the Secretary of	

	
   the Department to act on the applicant's behalf	

	

	
	
  Other-If other, specify:	

	

	

A15	
 Family name of correspondence recipient	

 	

First given name of correspondence recipient	

 	

	

A16	
 Correspondence recipient's address	

 	

	

 	

State                                   Postcode	

	

A17	
 Correspondence recipient's daytime contact number	

 (      )	

 Payment Details
 
A18	
CAPS payments can be received annually in July or half yearly in July and January. Tick one of the payment options below:	

	
  Full payment in July	

	

	
	
  Half payments in July and January	

	

A19	
 Is a representative or an organisation that is able to assist with the purchase of continence products to receive the CAPS payment on behalf of the applicant?	

	
  Yes - Go to A23	

	

	
	
  No -  Go to  A20	

A20	
 Applicant’s nominated bank account details	

	

Name of applicant’s nominated bank, building society or
credit union	

 	

	
Branch where the account is held	

 	

	

Branch number  (BSB)	

           -      	

	

Account Number	

 	

	

Account held in the name(s) of	

 	

	

A21	
Is a person other than the applicant signing the declaration
on this form?	

	
  Yes - Go to Section 2 - Representative details	

	

	
	
  No -  Go to  A22	

	

A22	
Applicant's declaration	

 I am the Applicant and I declare that:	

•	I have read the CAPS application guidelines;
•	the information on this form is true and correct; and
•	I will inform Medicare without delay of any changes to the information provided in this form.

I acknowledge:

•	giving false or misleading information is a serious offence and may lead to prosecution under the
Criminal Code Act 1995;
•	I may be asked to confirm my eligibility for CAPS payments;
•	the CAPS payment  provided  is for the purchase of continence products.	

Signature	

	

Date	

	

	

	 Continence Aids Payment Scheme Application Form  4	

Privacy Note
	Personal information  is protected by law, including by
	the Privacy Act 1988. Refer to page 2.
A23	
Is the CAPS payment to be made directly to an organisation or a representative?	

No	
	
 The applicant does not need to complete any	

	
 further questions – the Health Report – Section 3
 is to be completed by a Health Professional.

Yes	
	
 Go to Section 2 – Representative details for a	

	
 representative  or R15 to direct payment to an            organisation.	

NOTE: In all circumstances, for an applicant to be assessed as
eligible a Health Professional is required to complete Section 3
– the Health Report of this form. Please ensure the Health
 Professional has completed and signed Section 3 before
 returning this application to Medicare.

SECTION 2 - REPRESENTATIVE	

This section must be completed where either:
a)	a person other than the applicant is to sign the 			Representative’s declaration section of this form 			(see Who can complete this form? on page1); or
b)	a person other then the applicant is to receive a 			CAPS payment (see Who can receive payments? 		on page 1).
Documentary evidence of that person’s authority to act on behalf of the applicant/receive a payment on behalf of the applicant must be provided with this form.

Documentary evidence includes:
For a parent of an applicant:
•	Signing of the declaration section of this form 			(for a child under 14 years of age or for a child 			14 –17 years if they do not have the capacity to 		act on their own behalf.)

For a legal representative:
•	ƒ Guardianship papers;
•	ƒ Power of Attorney or Enduring Power of Attorney
 documents;
•	ƒ Court appointment documents; or
•	ƒ Other legal documentation, as applicable.

Certified copies of legal documents are to be provided. Do not send original documents. A certified copy is a copy of an original document that has been certified as a true and correct copy by a person authorised to witness a statutory declaration, for example a medical practitioner, a pharmacist or a public servant.

For a Centrelink Payment Nominee, documents (valid within the last 12 months) which prove your nominee status, for example:
•	ƒ a Centrelink Nominee Appointment letter.

For a Centrelink Correspondence Nominee, documents (valid within  the last 12 months) which prove your nominee status, for example:
•	ƒ Centrelink Payment Summary or Centrelink Account Statement that displays the name and address of the nominee and the name of the applicant;
•	ƒ a Centrelink Nominee Appointment letter.

		
For a DVA Trustee or Agent:
•	ƒ a DVA appointment of Trustee or Agent document.

Copies of original documents from Centrelink and DVA can be provided, however if they are copies they need to be certified.

For a responsible person approved by the Secretary of the Department:
•	ƒ evidence of the Secretary of the Department’s 			       written approval of the person as a responsible 		       person for the applicant.

The representative should advise Medicare if they no longer have authority to act on behalf of the applicant. An applicant can advise Medicare at any time if they wish to terminate their representative’s authority to act on their behalf (other than a legal representative).	

R1	
	
 What authorised actions will the representative be
 undertaking on behalf of the applicant?	

	

	
	
  Signing the form only Go to R8	

	

	
	
  Receiving the CAPS payment  only  Go to R2	

	

	
	
  Signing & directing the CAPS payment to an	

	
  organisation Go to R8	

	

	
	
  Signing  & receiving  the CAPS payment   Go to R2	

	

	
	
NOTE: If the payment representative and the signing form representative are different people, the payment representative is to complete the details in R2 to R7 and the signing form representative is to complete R8 to R12	

Representative receiving payment or
receiving payment and signing form on
behalf of the applicant

R2	
	
 What is the relationship of the representative receiving
the payment or receiving payment and signing form, to the applicant?	

	

	
	
  Applicant’s parent (applicant under 14 years of age)	

	

	
	
 Applicant’s parent (applicant 14 to 17 years of age) 	

	

	
	
 Person appointed under a Power of Attorney	

	

	
	
Person appointed under an Enduring Power of Attorney	

	

	
	
 Appointed legal guardian	

	

	
	
 Other legal representative, specify	

	

	

	
	
  Centrelink Correspondence Nominee (may sign form)	

	

	
	
 Centrelink Payment Nominee (may receive payments only) 	

	

	
	
 DVA Trustee (may sign form and receive payments)	

	

	
	
 DVA Agent (may receive payments only)	

	 Continence Aids Payment Scheme Application Form  5	

	
	
 Responsible person approved by the Secretary of  	

	
  the Department to act on the applicant’s behalf        (may sign form and/or receive payments)

	
	
 Responsible person approved by the Secretary of	

	
 the Department to receive payments on applicant’s        behalf (may receive payments only)

R3	
Organisation name (only if required), for example if
representative is a Public Trustee or a disability facility.	

 	

	

Name of contact person in organisation	

         	

	

Contact person’s position	

 	

	

R4	
Family name of representative	

 	

	

First given name of representative	

         	

	

R5	
 Address	

 	

	

 	

State                                   Postcode	

	

R6	
 Daytime contact number	

 (      )	

Representative’s bank account details

R7	
Name of bank, building society or credit union	

 	

Branch where the account is held	

 	

	

Branch number  (BSB)	

           -      	

	

Account Number	

 	

	

Account held in the name(s) of	

 	

	

NOTE: If a representative is not signing the declaration on behalf of the applicant there are no further questions. Section 3 – theHealth Report needs to be completed by a Health Professional.	Representative signing form ONLY

R8	
	
 What is the relationship of the representative signing      the form, to the applicant?	

	

	
	
  Applicant’s parent (applicant under 14 years of age)	

	

	
	
 Applicant’s parent (applicant 14 to 17 years of age) 	

	

	
	
 Person appointed under a Power of Attorney	

	

	
	
Person appointed under an Enduring Power of Attorney	

	

	
	
 Appointed legal guardian	

	

	
	
 Other legal representative, specify	

	

	

	
	
  Centrelink Correspondence Nominee 	

	

	
	
 DVA Trustee	

	

	
	
 Responsible person approved by the Secretary of the 	

	
   Department to act on the applicant’s behalf	

R9	
Organisation name (if required), for example if
representative is a Public Trustee or a disability facility.	

 	

	

Name of contact person in organisation	

         	

	

Contact person’s position	

 	

	

R10	
Family name of representative	

 	

	

First given name of representative	

         	

	

R11	
 Address	

 	

	

 	

State                                   Postcode	

	

R12	
 Daytime contact number	

 (      )	

	 Continence Aids Payment Scheme Application Form  6	

Representative’s declaration
R13	
	
 I am the 	

	

	
	
  Applicant’s parent (applicant under 14 years of age)	

	

	
	
 Applicant’s parent (applicant 14 to 17 years of age     	

	
 and do not have the capacity to act on their own           behalf)	

	

	
	
 Person appointed under a Power of Attorney	

	

	
	
Person appointed under an Enduring Power of Attorney	

	

	
	
 Applicant's Appointed legal guardian	

	

	
	
 Applicant's other legal representative, specify	

	

	

	
	
  Applicant's Centrelink Correspondence Nominee 	

	
   (applicant unable to act on own behalf due to a              physical or mental impairment)	

	

	
	
 Applicant's DVA Trustee(applicant unable to act on 	

	
   own behalf due to a physical or mental impairment)	

	

	
	
 Responsible person approved by the Secretary of the 	

	
   Department to act on the applicant’s behalf	

I declare that:

•	I have read the CAPS application guidelines;
•	the information on this form is true and correct;
•	I will inform Medicare without delay of any changes to the information provided in this form;and 

I acknowledge:

•	giving false or misleading information is a serious offence and may lead to prosecution under the Criminal Code Act 1995;
•	I may be asked to confirm the applicant's eligibility for CAPS payments; and
•	the CAPS payment  provided  is for the purchase of continence products for the applicant	

	

Signature	

	

Date	

	

	Privacy Note
	Personal information  is protected by law, including by 		the Privacy Act 1988. 
R14	
IDo you wish the CAPS payment to be made directly to an organisation ?	

Yes	
	
 Go to R15	

	

No	
	
 You do not need to complete any further questions	

	
 – the Health Report – Section 3 is to be completed by a Health Professional.	

R15	
	
 Authorising payment to an organisation	

	
If an organisation agrees to receive the CAPS payments on behalf of an applicant, the organisation must complete the Organisation authorised as payment recipient section (see page 8) of this form.

	
	
 I am the 	

	

	
	
 Applicant	

	

	
	
  Applicant’s parent (applicant under 14 years of age)	

	

	
	
 Applicant’s parent (applicant 14 to 17 years of age     	

	

	
	
 Person appointed under a Power of Attorney	

	

	
	
Person appointed under an Enduring Power of Attorney	

	

	
	
 Applicant's Appointed legal guardian	

	

	
	
 Applicant's other legal representative, specify	

	

	

	
	
  Applicant's Centrelink Correspondence Nominee 	

	

	
	
 Applicant's DVA Trustee	

	

	
	
 Responsible person approved by the Secretary of the 	

	
  Department to act on the applicant’s behalf	

   I authorise  the CAPS payment  to be paid to the following
   organisation:

Organisation name	

 	

	

Organisation Australian Business Number (ABN)	

 	

	

Signature	

	

Date	

	

	Privacy Note
	Personal information  is protected by law, including by 			the Privacy Act 1988. Refer to page 2.
NOTE: In all circumstances, for an applicant to be assessed as eligible a Health Professional is required to complete Section  3 – the Health Report of this form. Please ensure the Health Professional has completed and signed Section 3 before
 returning this application to Medicare.	
	 Continence Aids Payment Scheme Application Form  7	

 
Organisation authorised as payment recipient

If an organisation agrees to receive CAPS payments  on behalf  of an applicant, the organisation must complete this section of the form.	

 Organisation Details

R16	
Organisation name	

 	

	

R17	
Organisation’s Australian Business Number (ABN)	

         	

	

R18	
Name of organisation’s authorised representative	

 	

	

R19	
Position of organisation’s authorised representative	

 	

	

R20	
Contact Number	

  (     )       	

	

R21	
 Organisation's business Address	

 	

	

 	

State                                   Postcode	

	

R22	
 Organisation's postal Address	

 	

	

 	

State                                   Postcode	

	

Organisation’s bank account

CAPS payments  will be made to this bank account. The account recorded must be an Australian bank account. Payments cannot be made into credit cards, loan or mortgage accounts.

R23	
Name of bank, building society or credit union	

 	

	

Branch where account is held	

 	

	

Branch number  (BSB)	

           -      	

	

Account Number	

 	

	

Account name	

 	

	

Organisation’s declaration

R24	
I declare that:

•	ƒ I am an authorised representative of the organisation
	identified at Question R18;
•	as the representative of the organisation, I am 				authorised to bind the organisation;
•	ƒ the information on this form is true and correct; and
•	   the organisation will inform Medicare without delay 		   of any changes to the information provided in this 		   form.
The organisation will:
•	ƒ ensure the CAPS payment  is used exclusively  for
	       the benefit of:

Applicant's name	

 <<Patient Demographics:Full Name>>	

	

Applicant's date of birth	

  <<Patient Demographics:DOB>>       	

	

•	ƒ ensure the CAPS payment  is used for the purchase
	   of appropriate  continence products or continence 			   related products for the applicant;
•	ƒ keep a record of all CAPS payments received;
•	keep records of continence and continence related aids purchased using a CAPS payment  (or a portion of a CAPS payment); and
•	return any unused CAPS payments  to the applicant, or the applicant’s estate, if advised that the applicant has died, is not eligible or is no longer eligible or the applicant or their representative terminates the payment arrangement with the organisation.

I acknowledge:
•	ƒ giving false or misleading information is a serious 				offence and may lead to prosecution under the 				Criminal Code Act 1995.

	

	

Signature	

	

Date	

	

Privacy Note
Personal information  is protected by law, including by the
Privacy Act 1988. Refer to page 2.

NOTE: The organisation should check that the Health Report
– Section  3 has been completed before forwarding the application to Medicare.
	
	 Continence Aids Payment Scheme Application Form  8	

 SECTION 3 - HEALTH  REPORT 	

Instructions for Health Professional

Please ensure you have read the CAPS application guidelines.

You should only complete this Health Report if you are in a position to make an accurate assessment of the applicant in relation to theirincontinence and its cause.

If in doubt, check the website www.bladderbowel.gov.au.

H1	
Name of Patient	

<<Patient Demographics:Full Name>>	

	

Applicant's Date of Birth	

<<Patient Demographics:DOB>>	

	

H2	
Do you have a Medicare Approved Provider Number	

No	q	

Yes	q	

	What is your Approved Provider Number	

<<Doctor:Provider Number>>	

	

H3	
Health Professional's Name	

<<Miscellaneous:Current User>>	

Given Names	

	

	

H4	
Health Professional's Contact details	

Phone number	

<<Practice:Phone>>	

Mobile Phone Number	

 	

Fax Number	

<<Practice:Fax>>	

Email address	

 <<Doctor:E-mail>>	

Business or Employer's Business Name	

<<Practice:Name>>	

Work Address	

<<Practice:Address>>	

	

H5	
To which health profession do you belong?	

	
	Continence nurse	

x	
	General Practitioner	

	
	Medical Specialist	

	
	Community Nurse		

	
	Physiotherapist	

	
	Occupational Therapist	

	
	Registered Nurse	

	
	Aboriginal Health worker	

	
	Other (specify)	

	

	

H6	
 Are you in a position to make an accurate continence assessment of the applicant?	

Yes	q	No	q	

	

H7	
Are you aware of a continence management plan for the applicant or can you refer the applicant for a continence management plan?	

 Yes	q	No	q		

	

H8	
Does the applicant have permanent and severe incontinence caused by an eligible Neurological condition?	

No	q	

Yes	q  Specify Neurological condition.	

	

	

H9	
Does the applicant have permanent and severe incontinence caused by an eligible other condition and the applicant has a valid Centrelink or DVA Pensioner Concession Card (PCC) entitlement or is a listed as a dependant.	

No	q	

Yes	q  Specify other condition.	

	

	

	

	

H10	
Does the applicant have permanent and severe loss of bladder function?	

 Yes	q	No	q	

	

H11	
Does the applicant have permanent and severe loss of bowel function?	

 Yes	q	No	q	

	

H12	
Health Professional Declaration

I declare:
   I have assessed the applicant identified at H1 and A2: and
   to the best of my knowledge the information provided in          this Health report is true and correct.	

	

Signature	

	

Date	

<<Miscellaneous:Date (short)>>	

	

Privacy Note
Personal information is protected by law, including by the Privacy Act 1988. Refer to page 2.	

	Continence Aids Payment Scheme Application Form  9