Ndss Test Strip Six Month Approval
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1Blood Glucose Test Strip Six Month Approval
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered with the assistance of Diabetes Australia.
Certifier
This form allows access to additional subsidised blood glucose testing strips after the initial six month period provided by the Scheme.
Only to be completed by a registered medical practitioner,
Person with diabetes
Guardian or carer
nurse practitioner, or credentialled diabetes educator (CDE).
If the person with diabetes is under 15 years old, or is an adult
12 Main reason for extension Choose one only
1 Given name(s)
receiving ongoing care, this section must be completed by a
Inter-current illness
(INT)
primary guardian or carer.
Medication affecting blood glucose
(MED)
2 Family name
9 Given name(s)
Clinical need for self-monitoring
(CON)
Diabetes management change
(MON)
Diabetes management not stable
(MAN)
10 Family name
3 Date of birth
13 Which are you? Choose one only.
If person with diabetes is under 15
Day
Month
Year
/
/
years old, the “Guardian or carer”
CDE
Endocrinologist
section must also be completed.
11 By signing here, you are confirming that:
GP
Nurse practitioner
• you are a primary guardian or carer for the person
Other registered medical practitioner
Describe:
4 Medicare card (preferred) or DVA file number
named in Q1 and Q2; and
• the information you and the person with diabetes
have provided on this form is true and complete; and
14 Your full contact details OK to use stamp
• both you and the person with diabetes agree to
5 Optional NDSS card number
Your name
the collection, use and disclosure of the provided
information for the purposes set out in this form.
Medicare provider
number/CDE number
Signed
Dated
Clinic/Hospital name
/
/
6 Are you of Aboriginal or Torres Strait Islander origin?
Tick all boxes that apply.
Address line 1
No
Lodging this form
Address line 2
Yes, Aboriginal
Must be certified (on right) by your health professional.
Suburb
Yes, Torres Strait Islander
In person: NDSS Access Points
State
Fax: 1300 536 953
7 Can we contact you about research opportunities?
Email: .au
Postcode
Yes
No
Post: GPO Box 9824 in your capital city
Phone number
8 By signing here, you are confirming that the
Need help with this form?
Fax number
information you have provided on this form is true
Call 1300 136 588 or visit .au
and complete, and that you agree to the collection,
15 By signing here, you are confirming the person named
TTY: 133 677
Speak and Listen: 1300 555 727
use and disclosure of your information for the
in Q1 and Q2 needs additional access to subsidised
Translation: 131 450
Internet Relay: .au
purposes set out in this form.
blood glucose testing strips, for the reason given in Q12.
Signed
Dated
Your information is protected by Commonwealth laws including the Privacy
Signed
Dated
/
/
/
/
Act 1988. Diabetes Australia and our Agents are committed to protecting your
privacy. For our privacy policy visit .au or call 1300 136 588.
NDSSBGTSForm20160628
Diabetes Australia: ABN 47 008 528 461, Quality Management System ISO 9001:2008 Certificate FS520906
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