Home Care Package Request Form

Home Care Package Billing Request Form

If you are an HCP Provider and would like to arrange 70/30 split billing for your client, please complete this form
We will send your client or their representative an information pack if not already provided. Packs are mailed once a week or emailed within 24 business hours.

To commence services: a completed payment authorisation and order request form must be submitted.
Both of these are included in the information pack.

View the 2024/25 Menu
For a print-friendly PDF, scroll to the bottom of the webpage.
Due to systems upgrades, we do not anticipate a new menu release until late 2025.

LGAs serviced*	Available Delivery Days
Ku-ring-gai	Monday to Friday to all suburbs
Hornsby Shire	Mondays, Wednesdays & Fridays Beecroft, Cheltenham, North Epping, Westleigh & Thornleigh Tuesdays only Arcadia, Galston, Fiddletown Dural, Middle Dural, Glenhaven & Glenorie –service not available (outside ACPR service area) Monday to Friday for all remaining suburbs
Northern Beaches	Monday to Friday to serviceable suburbs (generally suburbs north of Curl Curl + Forest District) Clients within the Manly Council electorate (https://en.wikipedia.org/wiki/Electoral_district_of_Manly#/map/0), except those in North Curl Curl and Dee Why, should contact Manly Meals on Wheels for services to be set up.

There are some suburbs that span across two local government areas (LGAs). To provide services, the client must reside in either the Ku-ring-gai, Hornsby or Northern Beaches Council area and the Northern Sydney Aged Care Planning Region (ACPR).

LGA by address can be checked at www.olg.nsw.gov.au/public/find-my-council/
ACPRs can be checked at https://www.gen-agedcaredata.gov.au/resources/access-data/2018/may/aged-care-planning-region-maps

Information Pack Requirements
To whom should we send an information pack?*

Client - email addressClient - postal addressRepresentative - email addressN/A. Already provided to client or representative.Other
Client Details
Client's Name*

TitleFirst NameSurname
Village Chef Client Status:*

New clientExisting clientUnsure
Client's Date of Birth*

DayMonthYear
Date
Client's Gender*

FemaleMaleOther
Client's My Aged Care Number:*
Required for government statistical reporting purposes.
Client's Address*

Street Address

Suburb

SuburbState

Post Code
Client's Phone Number (preferred)*
No spaces. Please include area code for landlines
Client's Phone Number (alternative)
No spaces. Please include area code for landlines
Client's Email Address:
example@example.com
Client's Emergency Contact/Representative (if applicable)

e.g. family or friend
Contact's Name:*
Please include first and last
Relationship to Client:*
e.g. son, daughter
Select all that apply:

Emergency contactPOAPerson to contact regarding service/service changes
Contact Person's Phone Number (preferred)*
No spaces. Please include area code for landlines
Contact Person's Phone Number (alternative)
No spaces. Please include area code for landlines
Contact Person's Email:
example@example.com
Additional Notes/Comments:
e.g. delivery instructions, additional emergency contacts
Home Care Provider's Details
HCP/Provider Company Name:*
HCP/Provider ABN:*
Case Worker's Name:*
Please include first name and surname
Case Worker's Direct Phone Number:*
No spaces. Please include area code for landlines
Case Worker's Email:*
example@example.com
Billing Information
Client Reference Number:
If applicable
Purchase Order Number:
If applicable
Account's Department Email (if different):
example@example.com
Account's Phone Number:
No spaces
HCP Client Price List

Prices will increase at the start of the 2025/26 financial year.
*Petite meal and bread roll available Northern Beaches only.
I confirm that I have reviewed and agree to the price list above, acknowledging that prices will increase at the start of each new financial year.*

Yes
I confirm that I have provided the necessary client reference number and/or purchase order number to ensure timely payment of accounts.*

Yes
I understand that it is my responsibility to advise the client and or representative of out-of-pocket costs.*

Yes
I understand that the client, in consultation with me/my organisation, is responsible monitoring their assigned budget and expenditure.*

Yes
If the client has a representative, they are aware that The Village Chef may contact them to provide any necessary setup resources.*

YesNot yetClient does not have a representative
I understand that the client and/or their representative is responsible for completing the required paperwork (Order Request Form and Direct Debit Authority) before services can commence. If the service is essential, I acknowledge my role in monitoring its progress and providing assistance.*

Yes
Signature

Clear
Approved By

First NameSurname
Date

DayMonthYear
Should be Empty:

Home Care Package Billing Request Form

LGAs serviced*

Available Delivery Days

Information Pack Requirements

Client Details

Client's Emergency Contact/Representative (if applicable)

Additional Notes/Comments:

Home Care Provider's Details

Billing Information