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.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

You can upload this form in HPOS.

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Page last updated: 10 August 2020