Aged care application for the dementia and cognition supplement in home care form (AC014)

Use this form to advise us that a care recipient within your aged care service is eligible to receive the Dementia and Cognition Supplement.

Download and complete the Aged care application for the dementia and cognition supplement in home care form.

An authorised person of the approved provider must complete and sign this form.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 3 March 2022