Positron emission tomography - statutory declaration form (HW064)

Use this form to list the provider number and Location Specific Practice Number (LSPN) of the diagnostic imaging practice applying to perform PET services.

Download and complete the Positron emission tomography - statutory declaration.

PET is the Positron Emission Tomography.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

You can upload this form in HPOS.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 28 July 2022