Fillable Printable NDSS Registration Form - Australia
Fillable Printable NDSS Registration Form - Australia
NDSS Registration Form - Australia
Registration Form
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia.
NDSSRegForm201312
This form lets you register for the National Diabetes Services Scheme (NDSS) and the National Gestational Diabetes
Register (NGDR).
Who should
fill out this
form
You can use this form if you:
• live in Australia
and
• have a current Medicare Card, Department of Veterans’ Affairs (DVA) Gold Card, DVA
White Card specific to diabetes, 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, type 2 or gestational diabetes, or
• have been diagnosed with diabetes caused by a genetic defect, pancreatic disease,
hormonal abnormality or exposure to certain drugs and chemicals.
A primary guardian or carer needs to fill out part of this form if the person with diabetes:
• is under 15 years old, or
• is 15 or over and receives ongoing care.
After those details are complete, the form must be certified by a registered medical practitioner
such as your doctor, endocrinologist or obstetrician, or by a credentialled diabetes educator.
How to
fill out
this form
1. Fill out page 1 and the left-hand side of page 2, printing clearly with a black or blue pen.
2. If the person with diabetes is under 15 years old or is an adult receiving ongoing care, a primary
guardian or carer needs to complete the “Guardian or carer” section starting on page 2.
3. Take the form to a registered medical practitioner or credentialled diabetes educator and ask them
to certify it.
4. Send the certified form to Diabetes Australia:
Post: GPO Box 9824 in your capital city.
Fax
: 1300 536 953.
Email: Send a scanned copy to [email protected]
NDSS Access Point: Many pharmacies are NDSS Access Points. Ask your pharmacy if they
can accept this form.
NDSS Agent: Take the form to a local diabetes organisation office in your area. There is more
information about NDSS Agents on the next page.
For more
information
or help
Information about your privacy is explained on the next page. Common questions are answered
on the back of this form.
If you need more information or help filling out this form, call the NDSS Infoline on
1300 136 588,
or visit the website at ndss.com.au
Diabetes Australia: ABN 47 008 528 461, Quality Management System ISO 9001:2008 Certificate FS520906
What is the National Gestational Diabetes Register
(NGDR)?
The NGDR is a program within the NDSS that provides
education and information for women with gestational diabetes.
The NGDR aims to help these women reduce their risk of
developing type 2 diabetes and manage their health into
the future.
What is the National Diabetes Services Scheme
(NDSS)?
The NDSS delivers education and information services to people
with diabetes. It also provides a range of diabetes products at a
subsidised cost.
It is an initiative of the Australian Government administered by
Diabetes Australia, and is free to register.
ABOUT THIS FORM
Have difficulty with English? Call the Translating
and Interpreting Service (TIS) National on 131 450
and ask for the number 1300 136 588.
Have difficulty hearing or speaking? Access TTY on 133 677,
Speak and Listen on 1300 555 727 or Internet Relay at
iprelay.com.au then enter the number 1300 136 588.
Infoline 1300 136 588
NDSSRegForm201312
YOUR PRIVACY
How we
use your
information
Diabetes Australia and NDSS Agents respect your privacy. We use your details to provide:
• information about the NDSS and about managing your diabetes
• education and support services
• access to products at subsidised prices.
We may also use your details to communicate with you about:
• research into diabetes and related health conditions, and
• your local state or territory diabetes organisation’s activities and services.
If you wish, once you have registered, you can ask us not to contact you about these matters.
You will still receive important information about diabetes and NDSS product safety issues.
You have a choice about 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.
Protecting
your
privacy
Your information is protected by Commonwealth laws including the Privacy Act 1988.
Diabetes Australia and its Agents are committed to protecting your privacy. Diabetes Australia has a
privacy policy. This 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 Diabetes Australia deals with privacy complaints. You can view our privacy policy at ndss.com.au
or ask for a copy by calling
1300 136 588.
Who can
access your
information
The information you give in this form will be accessed by:
1. Diabetes Australia, the Commonwealth, NDSS Agents and other organisations that deliver the
NDSS and related services on behalf of the Australian Government.
We share your personal information for the purposes of, and to manage, the NDSS. Sometimes we
need to share information that identifies you (for example, when we share your name and address
with a mailing house to send you NDSS information). Wherever possible, we will only share your
details in ways that do not identify you.
2. The Australian Institute of Health and Welfare, which uses your information for statistical analysis
for the Commonwealth, and to assist Diabetes Australia to manage the NDSS.
3. State and territory diabetes organisations, which are dedicated to assisting people with diabetes
and their carers. Your local organisation may contact you to help you with your diabetes.
4. Researchers. Australian diabetes researchers lead the world in searching for a cure, as well as
better ways to treat and manage the condition.
We provide researchers with information that does not identify you. But some important research can
only be done when people have been identified. In these cases, we will contact you (for example, by
letter) to ask whether or not you would like to participate in the research. Only if and when you give
your consent to participate will we share with researchers any information that identifies you.
5. Third parties. The Commonwealth may direct us to share your information with other
Commonwealth agencies or health service providers. Your information may also be shared with other
third parties as authorised or required by law.
NDSS Agents are the local diabetes organisation in each state or territory. These organisations provide a range of
education and support services, as well as diabetes products.
NDSS Access Points provide information about managing diabetes, sell diabetes products and accept completed NDSS
registration forms. Many pharmacies are NDSS Access Points, as are some health centres, clinics and hospitals.
To find or contact an NDSS Agent or Access Point, visit ndss.com.au or call
1300 136 588.
NDSS AGENTS AND ACCESS POINTS
ndss.com.au
NDSSRegForm201312
form design by formulate
FREQUENTLY ASKED QUESTIONS
How does
registration with the
NDSS help me?
The NDSS provides education and support to help you manage your diabetes.
Registering with the NDSS gives you access to a range of support services (delivered by your local
state or territory organisation):
• The NDSS Infoline at 1300 136 588, 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.
• A range of diabetes products at a subsidised cost.
Is everyone with
diabetes eligible for
the NDSS?
You can register for the NDSS if:
• you have been diagnosed with type 1, type 2 or gestational diabetes, or
• you have been diagnosed with diabetes caused by a genetic defect, pancreatic disease,
hormonal abnormality or exposure to certain drugs and chemicals.
You are not able to register if you have pre-diabetes or impaired glucose tolerance, or if your health
is being monitored in case you develop diabetes.
What if I do not
have an Australian
Medicare or DVA
card?
Visitors to Australia that are residents of Belgium, Finland, Italy, Malta, New Zealand, Norway,
Slovenia, Sweden, the Netherlands, the Republic of Ireland and the United Kingdom may be eligible
under a Reciprocal Health Care Agreement (RHCA). Visitors travelling on a student visa from
Finland, Malta, Norway and the Republic of Ireland are not covered by a RHCA and not eligible.
If you think a RHCA applies to you, please include a photocopy of your passport and your Australian
visa when you submit this form.
Who can certify my
form?
Only registered medical practitioners and credentialled diabetes educators can certify this form. If the
right person has not certified your form, we will not be able to process it.
Why do I need to tell
you where I live?
This form asks for the address where you live and your postal address. Knowing where you live
helps us plan diabetes services. We need your postal address so we can send you information.
Why do I have to
tell you about my
background?
We ask for your personal details so that we can give you the right support. The more we understand
about people who have diabetes, the more relevant we can make the services we deliver.
Why do you ask my
weight and height?
Weight and height are important elements for current research into diabetes management and
prevention. Even estimates of these measurements are very useful.
I am registering for
the NGDR. Why do
you ask about my
regular GP?
When you register for the NGDR, both you and your doctor will receive regular reminders about your
diabetes checks.
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. Then 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 credentialled diabetes
educator, registered medical practitioner or pharmacist to submit an NDSS “Medication Change
Form” for you. They can download it from ndss.com.au and should attach a photocopy of your
prescription to it.
What if my personal
or contact details
change?
Keep your NDSS registration up to date. Print the “Personal Details Update Form” at
ndss.com.au or ask for one at any NDSS Access Point. Fill it out and send it to the address
on the form, along with any extra information that is required.
NDSSRegForm201312
Page 1 of 3
Person with diabetes
The questions in this section are about the person with diabetes.
Please print clearly in black or blue pen.
All questions must be answered unless marked “(Optional)”.
3 Family name
11 Postal address
This is where we will send your NDSS card and other
information to help with the management of your diabetes.
2 Given name(s)
12 Email address
6 Date of birth
10 Is the address where you live (shown in Q9) also
your postal address?
Yes Go to 12
No Go to next question
4 (Optional) Previous name(s) e.g. maiden name
7 Daytime phone number (mobile preferred)
For landlines, please include the area code.
8 Alternative phone number e.g. home or partner
16 Are you a resident of Belgium, Italy, New Zealand,
Slovenia, Sweden, the Netherlands or the United
Kingdom?
No Go to next question
Yes Go to 20
20 In which country were you born?
Australia Go to 21
Other Country:
21 Which language you most often speak at home?
English Go to 22
Other Language:
22 Are you of Aboriginal or Torres Strait Islander
origin? Tick all boxes that apply.
No
Yes, Aboriginal
Yes, Torres Strait Islander
Note: If person with diabetes is
under 15 years old, the “Guardian
or carer” section (on the next page)
must also be completed.
1 Title e.g. Ms, Mrs, Miss, Mr, Dr
9 Address where you live
19 Please provide the following details
13 Do you have a gold DVA card?
No Go to 14
Yes File number:
5 Sex Male Female Intersex
17 Are you a resident of Finland, Malta, Norway or the
Republic of Ireland?
No You are not eligible for the NDSS
Yes Go to next question
18 Are you in Australia on a student visa?
No Go to next question
Yes You are not eligible for the NDSS
Include a photocopy of both your passport and
your visa when you lodge this form.
15 Do you have a current Medicare card?
Yes Number:
No Go to 16
14 Do you have a white, diabetes-specific, DVA card?
No Go to 15
Yes File number:
/ /
Day Month Year
Passport number
Country of issue
Visa expiry
/ /
Day Month Year
Line 2
Line 3
Suburb or town
State or territory
Postcode
Line 1
Line 2
Line 3
Suburb or town
State or territory
Postcode
Line 1
Include a photocopy of your
card when you lodge this form.
Go to 20
Go to 20
Go to 20
NDSSRegForm201312
Page 2 of 3
27 By signing here, you are confirming that you
require NDSS products and/or services for the
management of your diabetes, and that you agree
to the collection, use and disclosure of your
information for the purposes set out in this form.
Guardian or carer
If the person with diabetes is under 15 years old, or is an adult
receiving ongoing care, this section must be completed by a
primary guardian or carer. Details for a secondary guardian or
carer, if any, can be added after registration.
All questions must be answered unless marked “(Optional)”.
30 Family name
29 Given name(s)
31 Date of birth
35 Email address
34 Daytime phone number (mobile preferred)
For landlines, please include the area code.
36 Relationship to person with diabetes
37 By signing here, you are confirming that:
•you are a primary guardian or carer for the
person named in Q2 and Q3; and
•this person requires NDSS products and/or
services for the management of their diabetes; and
•both you and the person with diabetes agree to the
collection, use and disclosure of your information
for the purposes set out in this form.
33 Your postal address
28 Your title e.g. Ms, Mrs, Miss, Mr, Dr
What next?
Before lodging this form, make sure it is certified by a
registered medical practitioner or credentialled diabetes
educator by having them complete the next page.
23 In what month and year did a doctor first
diagnose your diabetes?
Or, if you don’t know the month and year,
approximately how long ago was it?
25 Where were you living when first diagnosed?
24 Were you living in Australia when first diagnosed?
Yes Go to 25
No Country you were living in:
Go to 26
In the last 12 months
Between 1 and 3 years ago
Between 3 and 5 years ago
Between 5 and 10 years ago
More than 10 years ago
26 Which of the following is the person with diabetes?
Under 15 years old
An adult receiving
ongoing care
Neither of the above Go to next question
What next?
Before lodging this form, make sure it is certified by a
registered medical practitioner or credentialled diabetes
educator by having them complete the next page.
Go to “Guardian or carer”
section (on right)
Lodgement method (tick all boxes that apply)
Card number
Issued by
Checked by
on
on
Received on
Mail Agent Email Fax
Access Point
AP Code: Contacted?
32 Is your postal address the same as the postal
address for the person with diabetes?
Yes Go to 34
No Go to next question
/ /
Signed Dated
OFFICE USE ONLY
/ /
/ /
/ /
Signed Dated
/ /
Day Month Year
/
Month Year
Suburb or town
State or territory
Postcode
Line 2
Line 3
Suburb or town
State or territory
Postcode
Line 1
/ /
NDSSRegForm201312
Page 3 of 3
47 Have the woman’s biological parents, sisters,
brothers or children had diabetes?
46 Baby’s expected date of birth
48 Name of woman’s regular GP and/or clinic (if any)
49 Street address for above-named GP/clinic
38 The diagnosis
Type 1 Go to 51
Type 2 Go to 39
Gestational (GDM) Go to 42
Other Go to 41
51 Is insulin required?
No Go to 52
Yes, injection
Yes, insulin pump
Date of first use:
52 Is an approved non-insulin injectable required?
No Go to 53
Yes, Byetta
®
Yes, Victoza
®
Date of first use:
Certifier
This section can only be completed by a registered medical
practitioner with a current Medicare provider number or a
credentialled diabetes educator (CDE) with a current Australian
Diabetes Educators Association (ADEA) CDE number.
All questions must be answered unless marked “(Optional)”.
42 When was GDM diagnosed?
43 Has this woman had GDM before?
Yes Go to next question
No Go to 46
44 In what years did this woman have GDM before?
45 Woman’s name(s) in these years (if different to now)
55 Your full contact details
Use any stamps or stickers you have, even if they do not
line up exactly with the prompts. The prompts are there for
those without stamps or stickers, and to make sure all the
information that we require is provided.
56 By signing here, you are confirming that you have
performed the diagnosis of diabetes, or sighted
written documentation relating to the diagnosis of
diabetes, for the person named in Q2 and Q3.
54 Which of these are you?
CDE
GP
Endocrinologist
Obstetrician
Other registered
medical practitioner Describe:
None of the above You cannot certify this form
Go to 55
50 GP/clinic daytime phone number Include area code.
41 Other diabetes diagnosis (to determine eligibility)
Go to 51
If more than two instances,
give the two most recent years.
53 (If known) height and weight at time of diagnosis,
or pre-pregnancy for women with GDM
Leave blank if not known.
Height Weight
39 How is the diabetes managed? Tick all that apply.
Yes No Do not know
40 Go to 51
Diet Exercise Tablets
/ /
Day Month Year
Year Year
Your name
Medicare provider
number/CDE number
Address line 1
Address line 2
Suburb
State
Postcode
Phone number
Fax number
Clinic/Hospital name
/ /
Signed Dated
/ /
Day Month Year
GP
Clinic
/ /
Day Month Year
Line 2
Suburb or town
State or territory
Postcode
Line 1
cm kg
/ /
Day Month Year
Given
name
Family
name
