Aged Care approved provider statement form (AC003)

Complete this form to declare that you have the appropriate business and security controls in place to ensure all claims, forms and other relevant documentation to claim payments of subsidy under the Aged Care Act 1997 are appropriately authorised. This form must be completed and signed by an authorised person of the approved provider.

The provider statement only needs to be completed if you are a provider with services not registered for Aged Care Online Claiming (ACOC).

The provider statement must be submitted every 3 years. The current provider statement is valid for the period 1 July 2014 to 30 June 2017.

If your organisation operates more than one aged care service, you can complete 1 statement, attaching a list of services. Each page must be signed by the key personnel.

Providers with services registered for ACOC have signed the ACOC terms and conditions, which include the provider statement’s terms and conditions.

Page last updated: 8 June 2016

This information was printed Wednesday 28 September 2016 from humanservices.gov.au/health-professionals/forms/ac003 It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.