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National Diabetes Services Scheme
ORDER FORM - Pen Needles/Syringes
Section 1 - NDSS Eligibility (You MUST provide the following information for your order to be completed. Please print clearly).
Medicare Number
or DVA File Number
NDSS Number
Section 2 - Details of Person with Diabetes (Please print clearly).
Title
Dr
Mrs
Mr
Ms
Other
Given
Name(s)
Family
Name
Date of Birth
Daytime
Phone No.
Address
State
Postcode
Delivery
Address
State
Postcode
Section 3 - Concession card details: If you are applying for a concession you must also provide the relevant number in the box(es) below
Card Type
Health Care Card
Pension Card / Concession Card
Card Number
Safety Net Card
Veterans Affairs Card (DVA)
Tick colour
Gold
White
Expiry Date
Section 4 - Declaration
Declaration: I certify that the NDSS products requested/received in response to this order are for the treatment of the above person’s
diabetes and that information relating to any entitlements to free or concessional benefits is not false or misleading.
Registrant’s
Signature (or carer)
Print Name of
Person Signing
If signing on behalf of Registrant please
provide your daytime contact phone number
Date
Section 5 - Payment Details: Please make Cheques / Money Orders payable to the NDSS Agent in your state or territory (see below).
Cash
Visa
Total
$
Cheque
Money Order Credit Card
Mastercard
Number
Cardholder’s
Name
Exp
Cardholder’s
Signature
/
x
Section 6 - NDSS Agent in your state / territory
ACT - Diabetes ACT
QLD - Diabetes Queensland
VIC - Diabetes Australia Victoria
NSW - Australian Diabetes Council
SA - Diabetes SA
WA - Diabetes WA
NT - Healthy Living NT
TAS - Diabetes Tasmania
NDSS Infoline 1300 136 588
Diabetes Australia and NDSS Agents regret they are NOT permitted to exchange NDSS products incorrectly ordered by Registrants
Please Note:
NDSS products cannot be dispatched unless you have provided all the necessary information and made the required payment.
Product limits are enforced. Diabetes Australia has an obligation not to supply amounts of product above the national levels of
average use, without written authorisation. These levels are 900 strips and/or 1200 syringes/needles per 180 day period.
Registrants who require supplies in excess of these amounts may complete an exemption form which is available from Diabetes
Australia.
Please note that some products have a use by date so, to avoid unnecessary wastage, take care not to over-order
items.
To have this order filled, you have the following options:
• Selected pharmacies and outlets are able to supply NDSS products (Access Point)
• Order over the counter at any NDSS Access Point, NDSS shop front or by phone 1300 136 588 (credit card required)
• Post this order form to Diabetes Australia GPO Box 9824 in your state or territory capital city (please do not send cash)
• To find your local Access Point please phone 1300 136 588 or visit www.ndss.com.au
All personal information is protected by the Privacy Act 1988.
A doctor’s prescription is not required to purchase NDSS products.
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia
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Version - October 2014
PRODUCT DESCRIPTION
Packs of
NDSS Code
Pen Needles
B-A Omnican Mini Pen Needle 30G x 8mm
B-D MicroFine + Pen Needle 29G x 12.7mm
B-D MicroFine + Pen Needle 31G x 8mm
B-D MicroFine + Pen Needle 31G x 5mm
B-D UltraFine Pentapoint Comfort Pen Needle 32G x 4mm
Mylife Clickfine Pen Needle 31G x 8mm
Mylife Clickfine Pen Needle 31G x 6mm
Mylife Clickfine Pen Needle 31G x 4.5mm
Mylife Clickfine Pen Needle 32G x 4mm
NovoFine Pen Needle 30G x 8mm
NovoFine Pen Needle Tip 32G x 6mm
NovoFine Plus Pen Needle 32G x 4mm
Unifine Pentips 29G x 12mm
Unifine Pentips 31G x 8mm
Unifine Pentips 31G x 6mm
Unifine Pentips 31G x 5mm
Syringes
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
67
87
92
97
101
217
216
230
231
91
150
165
215
214
213
235
Order QTY
Price
AMOUNT
PAYABLE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Terumo 0.3mL 29G x 13mm
100
99
FREE
Terumo 0.5mL 29G x 13mm
100
76
FREE
Terumo 1.0mL 29G x 13mm
100
77
FREE
B-D Ultra-Fine 0.3mL 29G x 12.7mm
100
88
FREE
B-D Ultra-Fine 0.5mL 29G x 12.7mm
100
89
FREE
B-D Ultra-Fine 1.0mL 29G x 12.7mm
100
90
FREE
B-D Ultra-Fine ll 0.3mL 31G x 8mm
100
201
FREE
B-D Ultra-Fine ll 0.5mL 31G x 8mm
100
202
FREE
B-D Ultra-Fine ll 1.0mL 31G x 8mm
100
203
FREE
Other Products (if ordering NDSS products, please include product number, product name and correct eligible pricing)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Total Amount Payable: $
Please Note if ordering other products:
If you are the holder of any of these cards you are entitled to further subsidies:
Health Care Card - Pension / Concession Card - Safety Net Card - Veterans’ Affairs Card
*In some areas DVA has agreed to pay your contribution - please telephone 1300 136 588 to enquire.
All State and Territory Governments have agreed to fund co-payment
for needles and syringes available under the Australian Government’s NDSS Scheme.
*Byetta (exenatide)
*Victoza (liraglutide)
As a result of this initiative, disposable syringes and pen needles are free to all eligible
NDSS Registrants for insulin and approved non-insulin injectable medication* use.
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia
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NDSS ORDER FORM - UPDATED 08.10.2014
8/10/14 8:50
11/12/13
4:09 AM
PM