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.

Download and complete the Aged care approved provider statement form.

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. You can fill it out on your device, or print it and complete it by hand.

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: 8 December 2020