Version September 2024 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
NDSS Registration Form
For what purpose do we use or disclose your information?
We use or disclose your personal and sensitive information
for the purposes of administering the NDSS and providing
programs, services, and activities.
We may use your information to:
•
conrm your identity and update your personal details
•
provide you with information about the NDSS, managing
your diabetes or sending reminder notices to you and
your health professionals about important aspects of your
diabetes management
•
invite you to participate in education, support services and
programs delivered by Diabetes Australia or your local
state and territory diabetes organisation, or other NDSS
programs requiring specic consent
•
provide training to you, (or if you are a student to your
school’s sta), on diabetes and diabetes management
•
provide information about access to subsidised
diabetes-related products, or related information such
as product recalls.
We may disclose your information to the following people
or entities:
•
the Commonwealth as represented by the Department of
Health, which funds the NDSS, to produce statistical and
evaluation reports on the NDSS and for administrative
purposes, or for public accountability purposes
•
the Australian Institute of Health and Welfare for inclusion
in the National (insulin-treated) Diabetes Register,
cross-checking against the National Death Index, statistical
analysis, to undertake data linkage activities with other
datasets for health research purposes and to facilitate
health research projects undertaken by researchers and
other parties
•
Commonwealth agencies, researchers, and other parties
to facilitate health and other research projects including
data linkage activities, or to plan for the emerging needs of
people with diabetes
•
other third parties for the purposes of administering
the NDSS (or providing NDSS programs, services, and
activities), including organisations that deliver services on
our behalf (such as mailing houses), or organisations that
provide services to us.
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.
About this form
This form allows you to register with 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. The NDSS provides
people with diabetes who are registered access to information
and resources, diabetes self-management education
programs, and 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 the
Privacy Act 1988 (Privacy Act) and the Australian Privacy
Principles (APPs) contained in the Privacy Act.
What information do we collect?
We may collect your personal information if the information is
reasonably necessary for administering the NDSS and any of its
programs, services, or activities, including providing information,
education, and support services to you or your carer.
When personal information is sensitive information (for
example, health information), it will only be collected if you
have consented to that information being collected, or if one
of the other exceptions applies under the APPs. 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.
Personal information that may be collected:
•
your name, gender, date and country or birth
•
contact details and address,
•
NDSS, Medicare, DVA or Concession card number
•
details of your guardian or carer
•
details of your usual GP and other health professional.
Sensitive information that may collected:
•
diabetes type
•
details of the medication and NDSS products you require
to manage your diabetes
•
main language spoken at home
•
if you are of Aboriginal or Torres Strait Islander origin
•
whether your immediate relatives have had diabetes and
how your diabetes is currently managed
•
health services provided to you
•
other health information.
It is your choice to provide information to us. However, it
will be necessary for us to collect your personal or sensitive
information if you would like to access certain NDSS products,
education and support services or programs. If you choose
to withhold the information we require, we may not be able to
provide the services you have requested.
NDSS Helpline 1800 637 700
ndss.com.au
Have diculty 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 diculty with English?
Call the Translating and Interpreting Service (TIS)
National on 131 450 and ask for the number
1800 637 700.
For more information regarding how to ll out this form
and FAQ’s see page 4 of this form.
Version September 2024 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
12 Do you hold a valid concession card?
Yes Fill in details No Go to 13
Type of Concession (tick boxes)
Health Care Card Pensioner Concession Card
Veteran Gold Card Veteran White Card
(with diabetes as an accepted condition)
Concession Card Number
Expiry
Day Month Year
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 an Aboriginal or Torres Strait Islander
Australian? (tick all boxes that apply)
No Yes, Australian 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
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
If the person named in Q1 and Q2 is
under 15 years old, the “Carer or guardian”
section must also be completed.
Version September 2024 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.
22 Title Given name(s)
23 Family name
24 Date of birth
Day Month Year
25 Address
Suburb State Postcode
26 Daytime phone number (mobile preferred)
27 Email (preferred method of contact)
28 Relationship to person named in Q1 and Q2
Certier
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.
29 Which of these are you?
Aboriginal Health Practitioner GP
CDE Nurse practitioner
Endocrinologist/Diabetologist Practice nurse
Other registered medical practitioner who specialises
in diabetes (please specify below)
30 Diabetes diagnosis
Type 1 Go to 36 Type 2 Go to 34
Gestational (GDM) Go to 31
Other (list condition) Go to 36
31 When was GDM diagnosed?
Day Month Year
32 Baby’s expected date of birth
Day Month Year
33 Has the woman’s biological parents, sisters,
brothers or children been diagnosed with diabetes?
Yes No Do not know
34 How is the diabetes managed?
Diet Exercise Tablets
35 Is the use of Victoza ® required?
Yes Fill in details No Go to 36
36 Is insulin required?
Yes Fill in details No Go to 37
Injection
Insulin pump
You will also need to ll out an Insulin Pump
Consumable Access Form
37 Certier details
Your full name
Medicare provider, CDE or AHPRA number
Email
Clinic/Hospital
Address line 1
Address line 2
Suburb State Postcode
Phone number
38 By signing here, I am certifying that, for the person
named in Q1 and Q2, I have either:
performed the diagnosis of diabetes,
OR
sighted the documentation relating to the diagnosis
of diabetes as an Aboriginal Health Practitioner, CDE
or practice nurse.
And conrm:
• That the person named in Q1 and Q2 requires NDSS products
and/or services for the management their diabetes; and
• The person(s) named in Q1 and Q2 (and Q22 & Q23 if listed)
agree to the collection, use and disclosure of their information
for the purposes set out in this form; and
• Where a carer is providing personal information about the
person named in Q1 and Q2, they will advise the person of the
privacy information contained in this form; and
• The information provided on this form is true and complete; and
• I understand giving false and misleading information is a
serious offence.
Day MonthSignature Year
Date of rst use:
Day Month Year
Date of rst use:
Day Month Year
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 certied by an authorised health
professional such as your doctor, endocrinologist,
obstetrician, credentialled nurse educator, nurse
practitioner or practice nurse.
Lodging this form
Must be certied by your authorised health
professional.
Email: [email protected]
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-prot, 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 oer?
•
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 you and your carer.
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
and meet the eligibility criteria)
•
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.
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.
Version September 2024 NDSSFRM001
Diabetes Australia: ABN 47 008 528 461
