INSULIN PUMP CONSUMABLES ORDER FORM - NDSS

National Diabetes Services Scheme (NDSS) 

INSULIN PUMP CONSUMABLES 

ORDER FORM 

SECTION 1 – Medicare Card and NDSS Registration Card Numbers 

Medicare Number 

or DVA File Number 

SECTION 2 – Details of Person Utilising Insulin Pump Therapy 

Title 

Other 

Address 

Delivery 

Address 

Dr 

Mrs 

Mr 

Ms 

Given Name(s) 

Family Name 

Suburb 

or Town 

Suburb 

or Town 

Date of Birth 

Daytime 

Phone No. 

State 

Postcode 

Postcode 

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. 

Cardholder’s 

Signature (or Carer) 

Print Name of 

Person Signing 

NDSS NDSS Registration Registration Number 

Number 

State 

If signing on behalf of the registrant, please provide your address 

Date 

Postcode 

PRODUCT ORDERING GUIDELINES 

A doctor’s prescription is not necessary to purchase NDSS products. 

• Access to subsidised insulin pump consumables is dependent on meeting the Commonwealth’s criteria and 

completion/submission of the NDSS Assessment form – orders will not be accepted unless this condition is met. 

• Diabetes Australia regrets that it is not permitted to exchange NDSS goods incorrectly ordered by the registrant. 

• Please note that some products have a use by date so, to avoid unnecessary wastage, take care not to over-order 

these items. 

• The maximum number of product that can be supplied in any 180day period is 90 cannulae/needles and 90 reservoir/ 

cartridges – if you believe that you will exceed this limit, please contact the NDSS 

Under the conditions of the Commonwealth Head Agreement, Diabetes Australia (DA) cannot dispatch goods 

unless you have provided all the necessary information and made the required payment. 

STANDARD ORDERING OPTIONS 

• By phone or fax with a credit card. 

• Mail this order form and payment to: Diabetes Australia GPO Box 9824, in your state or territory capital city. 

• Order over the counter at your nearest Diabetes Australia office Please note: due to the large number of listed 

products, it will not always be possible for all products to be available ‘off-the-shelf’ when an order is placed over the 

counter. Contact your nearest NDSS agent on 1300 136 588 to find out whether your particular product will be 

available from the shop-front. 

All mail-orders will be sent to your delivery address (which must be located within Australia) by mail, free of any 

postage charges. 

Please allow 7 days for delivery to most areas or up to 14 days in remote areas. 

PRESENTATION OF CARDS 

• To ensure that only eligible people receive NDSS products, you will need to provide your NDSS Registration and 

Medicare card details when you make purchases from the NDSS. 

PRIVACY 

• If you have any questions in relation to privacy, please contact your local Diabetes Australia office on 1300 136 588. 

For further information, you can contact the NDSS agent in your state or territory on: 

1300 136 588 

The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government, administered by Diabetes Australia.

Version - June 2012 

NDSS 

Code 

NDSS IPC Order Form 

Product Description 

Supplier 

Code 

Supplier 

Catalogue No. 

Infusion Sets 

Connection 

Type 2 

Needle cannula 

angle & type 

No. Per box 3 

115 Soft Release O (6mm, 26G, 60cm) Manage S6051 Dana Proprietary sT 10 sets 15.00 




501 Deltec Comfort (17mm, 25G, 60cm) MSA 87-060-2652 Cozmo Luer lock aT 10 cannulae + 5 lines 12.50 



504 Deltec Comfort (17mm, 25G, 60cm) MSA 89-060-2622 Cozmo Luer lock aT 10 sets 15.00 



507 Cleo 90 (6mm, 28G, 61cm) MSA 21-7220-24 Generic Luer lock aT 10 sets 15.00 






513 Accu-Chek FlexLink (8mm, 30cm) Roche 4626427001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 






519 Accu-Chek FlexLink Cannula (8mm) Roche 4626567001 Spirit/H-Tron/D-Tron Luer lock sT 10 Cannula 10.50 

520 Accu-Chek FlexLink Cannula (10mm) Roche 4626575001 Spirit/H-Tron/D-Tron Luer lock sT 10 Cannula 10.50 

533 Accu-Chek TenderLink II 13/80 (13mm, 80cm) Roche 4541707001 Spirit/ D-Tron/D-Tron Plus/H-Tron Luer lock aT 20 cannulae + 10 lines 24.90 

537 Inset 30 Infusion set (13mm, 110cm) grey AMSL 100-396-03 Generic Luer lock aT 10 sets 15.00 

538 Inset 30 Infusion Set (13mm, 60cm) blue AMSL 100-396-01 Generic Luer lock aT 10 sets 15.00 

539 Inset 30 Infusion set (13mm, 60cm) pink AMSL 100-396-02 Generic Luer lock aT 10 sets 15.00 

540 Inset 30 Infusion set (13mm, 60cm) grey AMSL 100-396-00 Generic Luer lock aT 10 sets 15.00 

541 Animas Comfort (17mm, 27G, 60cm) AMSL 100-006-51 Generic Luer lock aT 10 sets 15.00 

542 Animas Comfort (17mm, 27G, 60cm) AMSL 100-006-03 Generic Luer lock aT 10 cannulae + 5 lines 12.50 

543 Animas Comfort (17mm, 27G, 110cm) AMSL 100-006-50 Generic Luer lock aT 10 sets 15.00 

544 Animas Comfort (17mm, 27G, 110cm) AMSL 100-006-02 Generic Luer lock aT 10 cannulae + 5 lines 12.50 

545 Inset II - includes insertion device (6mm, 27G, 60cm) grey AMSL 100-410-00 Generic Luer lock sT 10 sets 15.00 

545.1 Inset II - includes insertion device (6mm, 27G, 60cm) blue AMSL 100-410-01 Generic Luer lock sT 10 sets 15.00 

545.2 Inset II - includes insertion device (6mm, 27G, 60cm) pink AMSL 100-410-02 Generic Luer lock sT 10 sets 15.00 


546.1 Inset II - includes insertion device (9mm, 27G, 60cm) blue AMSL 100-411-01 Generic Luer lock sT 10 sets 15.00 

546.2 Inset II - includes insertion device (9mm, 27G, 60cm) pink AMSL 100-411-02 Generic Luer lock sT 10 sets 15.00 



549 Animas Comfort (60cm, 27G, 13mm) AMSL 100-240-01 Generic Luer lock aT 10 sets 15.00 

551 Animas Comfort (110cm, 27G, 13mm) AMSL 100-240-03 Generic Luer lock aT 10 sets 15.00 

552 Animas Comfort (60cm, 27G, 13mm) AMSL 100-240-04 Generic Luer lock aT 10 cannulae + 5 lines 12.50 

553 Animas Comfort (110cm, 27G, 13mm) AMSL 100-240-05 Generic Luer lock aT 10 cannulae + 5 lines 12.50 

561 Medtronic Paradigm Quickset (9mm, 25G, 110cm) Medtronic MMT-396 Paradigm Paradigm only sT 10 sets 15.00 




568 Medtronic Paradigm Silhouette (17mm, 25G, 110cm) Medtronic MMT-377 Paradigm Paradigm only aT 10 sets 15.00 


576 Medtronic Quick Sets (9mm, 25G, 110cm) Medtronic MMT-390 507/507c/508 Luer lock sT 10 sets 15.00 




582 Medtronic Silhouette (17mm, 25G, 110cm) Medtronic MMT-371 507/507c/508 Luer lock aT 10 sets 15.00 

583 Medtronic Silhouette (17mm, 25G, 60cm) Medtronic MMT-373 507/507c/508 Luer lock aT 10 sets 15.00 



590 Accu-Chek TenderLink Cannula (13mm) Roche 5015260001 H-Tron/D-Tron Luer lock aT 10 cannula 10.50 

Pump 1 

Price 

per box 4 No. 

Boxes 

$ 

Subtotal (A) $ 

Amount 

payable $

NDSS IPC Order Form continued 

NDSS 

Code 

Product Description 

Supplier 

Code 

Supplier 

Catalogue No. 

No. Per box 3 

591 Accu-Chek TenderLink Cannula (17mm) Roche 5015251001 H-Tron/D-Tron Luer lock aT 10 cannula 10.50 

592 Accu-Chek TenderLink 1 (13mm, 30cm) Roche 4541596001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 






603 Soft - Release ST (19mm, 26G, 70cm) Manage SR102 Dana Dana only aT 10 sets 15.00 

607 Superline Easy Release (7mm, 27G, 70cm) Manage SU313 Dana Dana only sm 10 sets 15.00 

611 Superline Easy Release II (7mm, 17G, 70cm) Manage SU401 Dana Dana only sm 10 sets 15.00 

615 Accu-Chek Rapid-D Link Cannula (6mm, 10cm tail) Roche 4541006001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 25 cannulae 26.30 



618 Accu-Chek Rapid-D Transfer Set (28G, 20cm) Roche 4541057001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 10 lines 4.50 






643 Medtronic Paradigm Mio (6mm, 27G, 45cm) pink Medtronic MMT-921 Paradigm Paradigm only sT 10 sets 15.00 

643.1 Medtronic Paradigm Mio (6mm, 27G, 45cm) blue Medtronic MMT-941 Paradigm Paradigm only sT 10 sets 15.00 





645.2 Medtronic Paradigm Mio (6mm, 27G, 80cm) clear Medtronic MMT-965 Paradigm Paradigm only sT 10 sets 15.00 

646 Medtronic Paradigm Mio (9mm, 27G, 80cm) clear Medtronic MMT-975 Paradigm Paradigm only sT 10 sets 15.00 

647 Medtronic Paradigm Sure - T (6mm, 29G, 60cm) Medtronic MMT-864 Paradigm Paradigm only sm 10 sets 15.00 






653 Medtronic Sure - T (6mm, 29G, 60cm) Medtronic MMT-863 507/507c/508 Luer lock sm 10 sets 15.00 





658 Medtronic Sure - T (10mm,29G,80cm) Medtronic MMT-885 507/507c/508 Luer lock sm 10 sets 15.00 



673 Contact Detach Infusion Set (6mm, 29G, 60cm) AMSL 100-905-00 Generic Luer lock sm 10 sets 15.00 




Pump 1 

Connection 

Type 2 

Needle cannula 

angle & type 

Price 

per box 4 No. 

Boxes 

$ 

Subtotal (B) $ 

Amount 

payable $

NDSS IPC Order Form continued 

Pump Reservoirs/Cartridges 

701 Animas IR1000 3mL AMSL 100-052-01 IR1000 na na 10 10.00 

702 Deltec Insulin Reservoir, 3mL MSA 21-1750-24 Cozmo na na 25 24.60 

704 Minimed Reservoir, 3mL Medtronic MMT-103A 507/507 c/508 na na 10 10.00 

705 Medtronic Paradigm Insulin Reservoir 1.8mL Medtronic MMT-326A 515/522/554 na na 10 10.00 

706 Medtronic Paradigm Insulin Reservoir 3mL Medtronic MMT-332A 715/722/754 na na 10 10.00 

709.1 Dana Reservoir 3mL Manage DAC00201 Dana only na na 10 10.00 

710 Animas IR1200/2020 Pump Cartridge 2mL AMSL AN100-124-01 IR1200 / 2020 na na 10 10.00 

711 Universal Reservoir 1.8mL MSA 1850-326A Universal na na 10 10.00 

712 Universal Reservoir 3.0mL MSA 3070-332A Universal na na 10 10.00 

713 Accu-Chek Spirit Cartridge 3.15mL Roche 5206073001 Spirit/ H-TRONplus na na 25 24.60 

714 Accu-Chek Spirit Cartridge 3.15mL Roche 4949935001 Spirit/ H-TRONplus na na 5 5.00 

Subtotal (C) $ 

Total Amount Payable 

(A+B+C) 

$ 

Office Use Only 

1 This column indicates manufacturer recommended pump for use with listed consumable. 

2 If a 'Lure lock' connection type is indicated, the product may be compatible with other pumps. Please note that the pump manufacturer may decline to provide support (or honour warranties) in the event that problems arise while utilising a pump 

3 'sets' indicates equal number of cannulae and lines, e.g. '10 sets' = 10 cannulae + 10 lines. 

4 Please note that there are no additional concessions on subsidised insulin pump consumables. 

# Inset products include an additional co-payment of $20.00 per box to fund the integrated inserter. 

Supplier codes: 

AMSL - Australasian Medical & Scientific Limited 

Medtronic - Medtronic Australasia 

Manage - Managing Diabetes 

Roche - Roche Diagnostics 

Needle/cannula angle & type: straight, metal = sm straight, Teflon = sT angled, metal = am angled, Teflon = aT 

The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia 

OPS.FM.RG.014 v1206 

NDSS ORDER FORM - UPDATED 01/06/2012

INSULIN PUMP CONSUMABLES ORDER FORM - NDSS

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