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.

PET is the Positron Emission Tomography.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

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Page last updated: 10 April 2019

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