Diabetes Australia: ABN 47 008 528 461 BGTSV1
Blood Glucose Monitoring
Strip Six Month Access Form
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
12 Title Given name(s)
13 Family name
14 Email (preferred method of contact)
15 Daytime phone number (mobile preferred)
16 Date of birth
Day Month Year
17 Address
Suburb State Postcode
18 Relationship to person named in Q1 and Q2
19Bysigninghere,Iamconrmingthat:
• I am the primary carer or guardian for the person named in
Q1 and Q2; and
• the information the person named in Q1 and I have provided on
this form is true and complete; and
• both the person named in Q1 and I agree to the collection, use and
disclosure of the provided information for the purposes set out in
this form and the NDSS Registration Form; and
• where I am providing personal information about the person
named in Q1 and Q2, I will advise that person of the privacy
information contained in this form; and
• I understand giving false or misleading information is a
serious offence.
Day MonthSignature Year
This form allows a person who is already registered
with the NDSS to access additional subsidised blood
glucose test strips after the initial six month period
through the Scheme.
Person with diabetes
1 Title Given name(s)
2 Family name
3 Date of birth
Day Month Year
4 Medicarecard(preferred)orDVAlenumber
5 NDSS card number
6 Are you of Aboriginal or Torres Strait Islander origin?
(tick all boxes that apply)
No Yes, Aboriginal Yes, Torres Strait Islander
7 Do you hold a valid concession card?
Yes Fill in details No Go to 8
Type of Concession
Health Care Card Pensioner Concession Card
Veteran Gold Card Veteran White Card
Concession Card Number
Expiry
Day Month Year
8 Daytime phone number (mobile preferred)
9 Email (preferred method of contact)
10 Address
Suburb State Postcode
11 Bysigninghere,Iamconrmingthat:
• the information I have provided on this form is true and complete;
and
• I agree to the collection, use and disclosure of my information for
the purposes set out in this form and the NDSS Registration Form;
and
• I understand giving false or misleading information is a
serious offence.
Day MonthSignature Year
PLEASE COMPLETE BOTH SIDES OF THIS FORM
If the person named in Q1 and Q2 is under
15 years old, the “Carer or guardian” section
must also be completed.
Version 4 January 2021 NDSSFRM002
Diabetes Australia: ABN 47 008 528 461
NDSS Helpline 1800 637 700
ndss.com.au
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, go to
ndss.com.au or call the NDSS Helpline on 1800 637 700.
Lodge this form in person
at your local
NDSS Access Point
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.
20 Which of these are you?
CDE
Endocrinologist/Diabetologist
GP
Nurse practitioner
Practice nurse
Other registered medical practitioner who specialises
in diabetes (please specify below)
21 Main reason for extension (Choose one only):
Inter-current illness (INT)
Clinical need for self-monitoring (CON)
Diabetes management not stable (MAN)
Medication affecting blood glucose (MED)
Diabetes management change (MON)
22Certierdetails
Your full name
Medicare provider, CDE or AHPRA number
Email
Clinic/Hospital
Address line 1
Address line 2
Suburb State Postcode
Phone number
23 By signing here, I am certifying that:
•
I have assesse
d the person named in Q1 and Q2; and
• they have a clinical need to access blood glucose test strips as
indicated by my answer to Q21.
Day MonthSignature Year
Privacy disclosure
Diabetes Australia respects your privacy and personal
information. You can view the NDSS Privacy Policy, which
contains information about how you can access and correct
your personal information held by us at ndss.com.au or
you can ask for a copy by calling the NDSS Helpline
on 1800 637 700.
The NDSS Registration Form contains details about how
we use, and who can access, your personal information.
This includes information provided in this form.
In addition to the entities identied in the NDSS Registration
Form, Diabetes Australia may disclose your personal
information provided in this form to NDSS Access Points and
also to third parties as authorised by the Commonwealth as
represented by the Department of Health (Commonwealth).
The Commonwealth may also track your usage of NDSS
subsidised products and your usage may be reported to your
treating health professional.
If you choose not to provide us with the information we need,
we may not be able to provide you with access to products
through the NDSS.
Version 4 January 2021 NDSSFRM002
Diabetes Australia: ABN 47 008 528 461
Need help with this form?
Call: 1800 637 700 or Visit: ndss.com.au
TTY
:
133 677 Speak and Listen
:
1300 555 727
Translation
:
131 450
Internet Relay:
internet-relay.nrscall.gov.au
