ORDER FORM: NDSS Helpline 1800 637 700

Monitoring Strips ndss.com.au

Section 1 - NDSS Eligibility (You Must provide the following information for your order to be completed. Please print clearly).
Medicare Number
NDSS Number or DVA File Number

Section 2 - Details of person with Diabetes (Please print clearly).

Title Dr Mr Given Family

Mrs Ms Name(s) Name
Daytime
Other Date of Birth Phone No.

Address State Postcode

Delivery
State Postcode
Address

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 Gold
Colour 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 the information provided relating to any entitlements for free or concessional benefits is not false or
misleading. I understand giving false or misleading information is a serious offence.
Registrant’s Print name of
Signature (or carer) Person Signing
If signing on behalf of registrant please
provide your daytime contact phone number Date

NDSS Helpline 1800 637 700 NDSS Fax 1300 536 953

Please note:
Diabetes Australia has an obligation not to supply product above the national levels of average use. These levels are
900 strips per 180 day period. Registrants who may require supplies in excess of these amounts should contact the NDSS
Helpline on 1800 637 700 to discuss their product requirements. Please note that NDSS products have a use by date, so, to
avoid unnecessary wastage, take care not to over-order these items.
Orders can be made over the counter at your local NDSS Access Point. Most community pharmacies are NDSS Access Points.
To find your nearest Access Point, please phone 1800 637 700 or visit ndss.com.au

Privacy
Diabetes Australia is governed by the Privacy Act 1988, which sets out how we handle your personal and sensitive information.
A copy of our current Privacy Policy is available at ndss.com.au or by contacting 1800 637 700.

Version November 2023. NDSSFRM014.

Diabetes Australia: ABN 47 008 528 461
 NDSS Packs Order Concession ATSI Pen/Conc (E) Amount
Product Description Product Application General
Code of QTY (A, B, C, D) SN Card (F) Payable

Blood Glucose Monitoring Strips PRICE PER PACK

135 Accu-Chek Aviva 50 Accu-Chek Aviva Expert, Accu-Chek Aviva Solo $7.50 $0.60 FREE
200 Accu Chek Guide 100 Accu-Chek Guide, Accu-Chek Guide Me, Accu-Chek Guide Link $15.00 $1.20 FREE
48 Accu-Chek Mobile 100 Accu-Chek Mobile $15.00 $1.20 FREE
107.5 Accu-Chek Performa 100 Accu-Chek Performa, Accu-Chek Performa Nano, Accu-Chek Performa Combo $15.00 $1.20 FREE
195 Contour Next 100 Contour Next, Contour NEXT ONE, Contour Next link, Contour NEXT link 2.4 $15.00 $1.20 FREE
322 CareSens N 100 CareSens N, CareSens N POP, CareSens N Voice, CareSens N Premier $15.00 $1.20 FREE
320 CareSens Pro 100 CareSens Dual $15.00 $1.20 FREE
44 Freestyle Lite 100 Freestyle Lite, FreeStyle Papillon mini, Freestyle Freedom Lite $15.00 $1.20 FREE
27 FreeStyle Optium 100 Optium, Optium Xceed, FreeStyle Optium Neo $15.00 $1.20 FREE
318 GlucoKey 100 GlucoKey $15.00 $1.20 FREE
330 GluNeo 100 GluNeo $15.00 $1.20 FREE
312 Lifesmart 2 Twoplus 100 LS - 946 $15.00 $1.20 FREE
332 GS700 100 Rightest GM700S, Rightest GM700SB $15.00 $1.20 FREE
316 TRUE METRIX 100 TRUE METRIX Air, TRUE METRIX Go $15.00 $1.20 FREE
Urine Monitoring Strips
31.50 Diastix Strips 50 Urine glucose indicator $3.60 $0.30 FREE
40.50 Keto - Diastix Strips 50 Ketone/glucose indicator $3.60 $0.30 FREE
Other Products (if ordering NDSS products, please include product number, product name and correct eligible pricing)

Total Amount Payable: $

If you are the holder of any of these cards you are entitled to further subsidies:
(A) Health Care Card (B) Pension Concession, Commonwealth Seniors’ Health Card (C) Safety Net CN Card
(D) Aboriginal and Torres Strait Islander peoples general price (E) Aboriginal and Torres Strait Islander peoples pension / concession card holder price (F) Safety Net SN Card
DVA Gold card holders, and DVA White* card holders NDSS co-payments are funded by the Department of Veterans’ Affairs (DVA).
No registrant payment for NDSS products is required for DVA Gold and White* card holders at Access Points. (*DVA white card holders must have diabetes as an accepted condition with DVA).

Version November 2023. NDSSFRM014.