Application for a Victorian Carer Card

Please do not print this page. Carers are welcome to download a PDF of the Application Form [PDF 159.4 KB].

If you can not access or view this form please access our online text only form.

Section one: your details

* Denotes required field.

Your Details
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Residential Street Address

To assist us to process your application include your entire residential street address with unit or house number and street name.

We cannot process your application if you provide a post box or roadside mailbox (RMB) address.

Postal Address if different from above:

Section two: cultural information (Optional)

Do you identify yourself as an Indigenous Australian?
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Do you speak a language other than English at home?

Section three: eligibility

You can confirm your eligibility for a Carer Card by:

  • providing your Centrelink Customer Reference Number (CRN) or your Department of Health & Human Services Vendor Number if you receive a carer payment or allowance
  • having a health professional verify your eligibility.

If you want to have a health professional confirm your eligibility, please print the Carer Card Application form [PDF 159.4 KB] and submit via post

  • Please provide confirmation of your entitlement for a Carer Card by providing the following information.
  • Please tick which category of carer you are applying under and fill in the matching field below. *
 

The CRN consists of nine digits and one alphabetic character and can be found on your Centrelink documentation. Please use your own CRN not your child's.

 

You will find this six digit number on the upper portion of your remittance advice sent to you by the Department of Health & Human Services. Please note, the form will display an error if a number that is not six digits long is entered into this field.

Section four: additional information (Optional)

The Carer Card is a new Victorian Government initiative. The Department of Health & Human Services is collecting additional information to ensure this program is best targeted to the needs of carers and is valued by both carers and participating businesses. Providing this information is voluntary.

The person you provide care for:
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Cardholder Agreement

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I authorise:

  • the Victorian Department of Health & Human Services (DHHS) to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my Centrelink Customer details and concession card status in order to enable the business to determine if I qualify for a concession, rebate or service.
  • the Australian Government Department of Human Services to provide the results of that enquiry to the Victorian Department of Health & Human Services.

I understand that:

  • the Australian Government Department of Human Services will use information I have provided to the Victorian DHHS to confirm my eligibility for the Carer Card and will disclose to the Victorian DHHS personal information including my name, address, payment and concession card type and status.
  • this consent, once signed, remains valid while I am a customer of the Victorian DHHS unless I withdraw it by contacting the Victorian DHHS or the Australian Government Department of Human Services.
  • I can obtain proof of my circumstances/details from the Australian Government Department of Human Services and provide it to the Victorian DHHS so that my eligibility for the Carer Card can be determined.
  • if I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the Carer Card provided by the Victorian DHHS.

You understand that the department may use your details to contact you to undertake research, evaluation or review of the Carer Card Program, for example, a survey or questionnaire. This is to ensure continuous improvement of this program. Participation is entirely voluntary.

Privacy and Your Rights

Is this application for a renewal Carer Card?

Please ensure that you complete this section if your current card is about the expire and you would like to apply for a new card.

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I understand and acknowledge that:

  • The information provided in this application is true and complete to the best of my knowledge
  • This application forms a legal document and penalties exist for providing false or misleading information
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29-9-2016

Privacy Statement

The Victorian Department of Health & Human Services is collecting information on this form to assist in the administration of the Carer Card Program. Personal information will not be disclosed to any third parties without your consent or unless required by law. The department may confirm business information with the Office of Fair Trading to assist with the assessment of your registration. Your business addresses and telephone numbers may be accessed by the public through the Carer Card website and directory. Personal details are protected by the Information Privacy Act 2009.