ORDER FORM - Pen Needles/Syringes - NDSS

ORDER FORM - Pen Needles/Syringes
Section 1 - NDSS Eligibility (You MUST provide the following information for your order to be completed. Please print clearly.)
NDSS Number
Section 2 - Details of Person with Diabetes (Please print clearly)
Title Dr Mr
Mrs Ms
Other
Address
Given
Name(s)
Date of
Birth
National Diabetes Services Scheme
Medicare Number
or DVA File Number
Family
Name
Daytime
Phone No.
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 Safety Net Card Veterans Affairs Card (DVA)
(Tick Colour)
Gold
White
Card Number
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
MasterCard
Money
Order
Cardholder’s
Name
Credit Card
Number
Verification
Code
Section 6 - NDSS Agent in your state / territory
3-digit CVV on the signature panel
on the back of the card
Cardholder’s
Signature X
ACT - Diabetes ACT NSW - Australian Diabetes Council NT - Health Living NT
QLD - Diabetes Australia Queensland SA - Diabetes SA TAS - Diabetes Tasmania
VIC - Diabetes Australia Victoria
WA - Diabetes WA
NDSS Helpline 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 fulfilled, 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 National Privacy Act 1988.
A doctor’s prescription is not required to purchase NDSS products.
Exp
/
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia

Version - March 2013
PRODUCT DESCRIPTION Packs of NDSS Code Order QTY Price
AMOUNT
PAYABLE
Pen Needles
B-A Omnican Mini Pen Needle 30G x 8mm 100 67 FREE n/a
B-D MicroFine + Pen Needle 29G x 12.7mm 100 87 FREE n/a
B-D MicroFine + Pen Needle 31G x 5mm 100 97 FREE n/a
B-D MicroFine + Pen Needle 31G x 8mm 100 92 FREE n/a
B-D MicroFine + Pen Needle 32G x 4mm 100 101 FREE n/a
100 218 FREE n/a
100 219 FREE n/a
100 216 FREE n/a
100 217 FREE n/a
100 230 FREE n/a
NovoFine Pen Needle 28G x 12mm 100 85 FREE n/a
NovoFine Pen Needle 30G x 8mm 100 91 FREE n/a
NovoFine Pen Needle 31G x 6mm 100 98 FREE n/a
NovoFine Pen Needle 32G x 6mm 100 150 FREE n/a
100 215 FREE n/a
100 213 FREE n/a
100 214 FREE n/a
Syringes
B-A Omnican 0.3mL 30G x 8mm 100 68 FREE n/a
B-A Omnican 0.5mL 30G x 8mm 100 69 FREE n/a
B-A Omnican 1.0mL 30G x 8mm 100 70 FREE n/a
B-A Omnican 1.0mL 30G x 12mm 100 73 FREE n/a
B-D Ultra-Fine 0.3mL 29G x 12.7mm 100 88 FREE n/a
B-D Ultra-Fine 0.5mL 29G x 12.7mm 100 89 FREE n/a
B-D Ultra-Fine 1.0mL 29G x 12.7mm 100 90 FREE n/a
B-D Ultra-Fine ll 0.3mL 31G x 8mm 100 201 FREE n/a
B-D Ultra-Fine ll 0.5mL 31G x 8mm 100 202 FREE n/a
B-D Ultra-Fine ll 1.0mL 31G x 8mm 100 203 FREE n/a
CM Safety Syringe 0.5mL 29G x 13mm 100 220 FREE n/a
CM Safety Syringe 0.5mL 30G x 13mm 100 221 FREE n/a
CM Safety Syringe 1.0mL 27G x 13mm 100 222 FREE n/a
CM Safety Syringe 1.0mL 29G x 13mm 100 223 FREE n/a
CM Safety Syringe 1.0mL 30G x 13mm 100 224 FREE n/a
Terumo 0.3mL 29G x 13mm 100 99 FREE n/a
Terumo 0.5mL 29G x 13mm 100 76 FREE n/a
Terumo 1.0mL 29G x 13mm 100 77 FREE n/a
Other Products (if ordering NDSS products, please include product number, product name and correct eligible pricing)
Please Note if ordering other products:
If you are the holder of any of these cards you are entitled to further subsidies: Total Amount Payable: $
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.
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.
*Byetta (exenatide)
*Victoza (liraglutide)
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia
OPS.FM.RG.012v1301 NDSS ORDER FORM UPDATED 21/03/2013