Aged Care approved provider statement form (AC003)

Use this form to declare that 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 if you are not registered for Aged Care Online Claiming (ACOC) - the provider statement terms and conditions are included in the ACOC terms and conditions.

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.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

Page last updated: 27 August 2017