Aged care approved provider statement form (AC003)

Use this form to declare you authorise all claims, forms and other relevant documentation to claim payments of subsidy under the Aged Care Act 1997.

If your organisation isn’t registered for Aged Care Online Claiming (ACOC), an authorised person of the approved provider must complete and sign this form.

You must submit the provider statement every 3 years. The current provider statement is valid for the period 1 July 2017 to 30 June 2020.

If your organisation operates more than 1 aged care service, you can complete 1 statement, with a list of services attached. The key personnel must sign each page.

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

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 13 February 2019