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.
Section two: cultural information (Optional)
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. *
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 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
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
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.