Version 9 August 2020 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
NDSS Registration Form
How do we use your information?
The information you give in this form will be used by
Diabetes Australia, the Commonwealth and other
organisations that deliver the NDSS and related
services.
We use or disclose your personal information to
administer the NDSS.
Your information may be used or disclosed to the
following:
the Commonwealth, as represented by the
Department of Health, who fund the NDSS, for
administrative or reporting purposes,
the Australian Institute of Health and Welfare for
statistical analysis and research,
other third parties for the purposes of administering
the NDSS, including organisations that deliver
services on our behalf, (such as mailing houses).
to communicate with you about:
research into diabetes and related health
conditions, and
your local state or territory diabetes organisation
and its activities or services.
Once you have registered with the NDSS, you can
ask us not to contact you about research or state
and territory activities. You will still receive important
information about the NDSS or product safety issues.
We are committed to protecting your privacy. The
NDSS Privacy Policy contains information about how
you can access and correct your personal information
held by us. The policy also explains how to complain
about a breach of your privacy and how we deal with
privacy complaints.
You can nd the NDSS Privacy Policy at
ndss.com.au or request a copy by calling the
NDSS Helpline on 1800 637 700.
For more information regarding how to ll out
this form and FAQ’s see page 4 of this form.
About this form
This form lets you register for the National Diabetes
Service Scheme (NDSS) and the National Gestational
Diabetes Register.
The NDSS is an initiative of the Australian Government
administered by Diabetes Australia, which
delivers
education and information services to support people
with diabetes. It also provides access to a range of
subsidised diabetes products.
The National Gestational Diabetes Register provides
postnatal reminders to women with gestational diabetes
and their nominated GP. The register aims to help these
women reduce their risk of developing type 2 diabetes
and manage their health into the future.
Your privacy
The information you provide the NDSS is protected by
Commonwealth laws including the Privacy Act (1988).
What information do we collect?
We collect your personal information to register you
with the NDSS and to administer the NDSS.
Your personal information may be collected on forms,
such as this form, when you contact the NDSS Helpline,
when purchasing NDSS products or in providing
information and services to you or your carer.
Examples of personal information that we collect, or
use includes:
your name;
contact details and address;
date of birth; and
details of your parent or carer.
Examples of sensitive information we may collect
incudes:
your diabetes type,
details of the medication and NDSS products you
require to manage your diabetes,
main language spoken at home, or
if you are of Aboriginal or Torres Strait Islander origin.
You have a choice whether or not to provide
information to us. If you choose not to provide us
with the information we need, we may not be able
to register you for the NDSS.
NDSS Helpline 1800 637 700
ndss.com.au
Have diculty hearing or speaking?
Access TTY on 133 677, Speak and Listen on
1300 555 727 or Internet Relay at
internet-relay.nrscall.gov.au then enter the number
1800 637 700.
Have diculty with English?
Call the Translating and Interpreting Service (TIS)
National on 131 450 and ask for the number
1800 637 700.
Version 9 August 2020 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
13 Daytime phone number (mobile preferred)
14 Alternative phone number
15 Address
Suburb State Postcode
16 In which country were you born?
Australia Other (please list)
17 Are you of Aboriginal or Torres Strait Islander origin?
(tick all boxes that apply)
No Yes, Aboriginal Yes, Torres Strait Islander
18 Which language do you most often speak at home?
English Other (please list)
19 When were you rst diagnosed?
(or approximate date)
Day Month Year
20 Were you living in Australia?
Yes Go to 21 No (please list) Go to 22
Country
21 Where in Australia were you living?
State Postcode
Suburb
22 By signing here, you are conrming that:
you require NDSS products and/or services for the management of
your diabetes; and
the information you have provided on this form is true and
complete; and
you agree to the collection, use and disclosure of your information
for the purposes set out in this form; and
you understand giving false or misleading information is a serious
offence.
Day MonthSignature Year
Person with diabetes
The questions in this section are about the person with
diabetes. Follow all instructions.
1 Title Given name(s)
2 Family name
3 Do you have a current Medicare card (preferred)
or DVA le number?
Yes ll in details and go to 8
No Go to 4
4 Are you a resident of Belgium, Italy, New Zealand,
Slovenia, Sweden, the Netherlands or the United
Kingdom?
Yes Go to 7 No Go to 5
5 Are you a resident of Finland, Malta, Norway or the
Republic of Ireland?
Yes Go to 6 No
You are not eligible for the NDSS
6 Are you in Australia on a student visa?
Yes
You are not eligible for the NDSS
No Go to 7
7 Please ll in details
Passport number
Country of issue Visa expiry
Day Month Year
8 Email (preferred method of contact)
9 Previous Name (optional)
10 Sex
Male Female Intersex
11 Date of birth
Day Month Year
12 Do you hold a valid concession card?
Yes Fill in details No Go to 13
Type of Concession
Health Care Card Pensioner Concession Card
Veteran Gold Card Veteran White Card
Concession Card Number
Expiry
Day Month Year
If the person named in Q1 and Q2 is
under 15 years old, the “Carer or guardian”
section must also be completed.
Version 9 August 2020 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
Carer or guardian
This section must be completed by a primary carer or
guardian if the person named in Q1 and Q2 is:
aged 15 years or under; or
aged 16 years or older and requires a primary carer
or guardian.
23 Title Given name(s)
24 Family name
25 Date of birth
Day Month Year
26 Address
Suburb State Postcode
27 Daytime phone number (mobile preferred)
28 Email (preferred method of contact)
29 Relationship to person named in Q1 and Q2
30 By signing here, you are conrming that:
you are a primary carer or guardian for the person named in
Q1 and Q2; and
the person named in Q1 and Q2 requires NDSS products and/or
services for the management of their diabetes; and
the information both you and the person named in Q1 and Q2 have
provided on this form is true and complete; and
both you and the person named in Q1 and Q2 agree to the
collection, use and disclosure of your information for the purposes
set out in this form; and
where you are providing personal information about the person
named in Q1 and Q2, you will advise that person of the privacy
information contained in this form; and
you understand giving false or misleading information is a
serious offence.
Day MonthSignature Year
Certier
This section can only be completed by an authorised
health professional with a current Medicare provider
number or a credentialled diabetes educator (CDE) with
a current Australian Diabetes Educators Association
(ADEA) CDE number or a practice nurse with a current
Australian Health Practitioner Regulation Agency
(AHPRA) registration number.
31 Which of these are you?
CDE GP
Diabetologist Nurse practitioner
Endocrinologist Practice nurse
Other registered medical practitioner who specialises
in diabetes (please specify below)
32 Diabetes diagnosis
Type 1 Go to 39 Type 2 Go to 37
Gestational (GDM) Go to 33
Other (list condition) Go to 39
33 When was GDM diagnosed?
Day
Month
Year
34 Baby’s expected date of birth
Day Month Year
35 Has the woman’s biological parents, sisters,
brothers or children been diagnosed with diabetes?
Yes No Do not know
36 Details of woman’s regular GP
When registering for the National Gestational Diabetes
Register, both the registrant and their GP will receive
regular reminders to check for diabetes.
Name of GP practice
GP name
Email
Address line 1
Address line 2
Suburb State Postcode
Phone
37 How is the diabetes managed?
Diet Exercise Tablets
38 Is an approved non-insulin injectable required?
Yes Fill in details No Go to 39
Victoza ®
Byetta ®
39 Is insulin required?
Yes Fill in details No Go to 40
Injection
Insulin pump
You will also need to ll out an Insulin Pump
Consumable Access Form
40 Certier details
Your full name
Medicare provider, CDE or AHPRA number
Email
Clinic/Hospital
Address line 1
Address line 2
Suburb State Postcode
Phone number
41 By signing here, you are certifying that, for the
person named in Q1 and Q2, you have either:
performed the diagnosis of diabetes,
OR
sighted the documentation relating to the diagnosis
of diabetes as a CDE or practice nurse.
Day MonthSignature Year
Date of rst use:
Day Month Year
Date of rst use:
Day Month Year
Version 9 August 2020 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
Who should ll out this form
You can register with the NDSS if you:
live in Australia, and
have a current Medicare card, Veteran gold or
white card, or
are a resident of a country with which Australia has a
Reciprocal Health Care Agreement (and not visiting
on a student visa if a resident of Finland, Malta,
Norway or the Republic of Ireland), and
have been diagnosed with type 1 diabetes, type 2
diabetes or gestational diabetes, or
have been diagnosed with diabetes caused by
a genetic defect, pancreatic disease, hormonal
abnormality or exposure to certain drugs or
chemicals.
The Carer or Guardian section of this form will need to
be completed if the person with diabetes is:
aged 15 years or under, or
16 years or older and requires a primary carer or
guardian.
The form must be certied by an authorised health
professional such as your doctor, endocrinologist,
obstetrician, credentialled nurse educator, nurse
practitioner or practice nurse.
Lodging this form
Must be certied by your authorised health
professional.
Email: ndss@diabetesaustralia.com.au
Fax: 1300 536 953
Post: GPO Box 9824 in your capital city
NDSS Access Point: Ask your pharmacy if
they can submit this form for you
NDSS Agents
All NDSS Agents are state and territory organisations
that are not-for-prot, member-based registered
charities.
Diabetes Australia appoints these organisations to
be NDSS Agents and provide NDSS support services
within their state or territory. Your state or territory
organisation can introduce you to the diabetes
community, services and programs near you.
NDSS Access Points
NDSS Access Points provide information about
managing diabetes, sell diabetes products and accept
completed NDSS forms. Many community pharmacies
are NDSS Access Points, as are some health centres,
clinics and hospitals.
To nd or contact an NDSS Agent or Access Point,
visit ndss.com.au or call 1800 637 700.
Frequently asked questions
How does registration with the NDSS help me?
Registration with the NDSS provides information and
support services, as well as diabetes-related products
at subsidised prices, to people with diabetes.
Registration is free and open to all eligible people
diagnosed with diabetes.
What does the NDSS oer?
access to a range of subsidised diabetes products
to help you manage your diabetes. Access to
products will vary depending on your needs,
the NDSS Helpline on 1800 637 700, which provides
information about diabetes and the NDSS,
education and support provided by diabetes
educators, dietitians and other health professionals,
programs and activities for people with diabetes and
their carers.
What types of diabetes products are available
through
the NDSS?
You can access a range of subsidised products
through the NDSS including:
blood glucose monitoring strips
urine monitoring strips
insulin pump consumables (if you have type 1 diabetes
or gestational diabetes and meet the eligibility criteria)
fully subsidised continuous and ash glucose
monitoring products (if you have type 1 diabetes, or
conditions similar to type 1 diabetes, and meet the
eligibility criteria)
fully subsidised insulin syringes and pen needles
(if you need insulin or approved non-insulin
injectable medications).
For more information visit ndss.com.au or call the
NDSS Helpline on 1800 637 700.
Why do I need to tell you personal information,
like where I live or who my GP is?
We ask for your personal details so that we can give
you the right support. The more we understand about
you, the more relevant we can make the services we
deliver. We need your postal address so we can send
you important information.
When you register for the National Gestational Diabetes
Register, both you and your GP will receive regular
reminders to check for diabetes.
What if my details change?
Complete the NDSS Personal Details Update Form at
ndss.com.au or ask for one at any NDSS Access Point.
Lodge this form with any supporting documentation
required.
What if the treatment for my diabetes changes?
If you start to use insulin or an approved injectable
blood glucose lowering medication, you need to tell
us so we can make sure you have access to the NDSS
products and services you need.
You do not need to complete a new NDSS Registration
Form. Ask your authorised health professional to submit
a Syringe or Pen Needle Access Form for you available
at ndss.com.au.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome