LSPN *

Are you registering? * A Diagnostic Imaging Practice
A base for mobile equipment

LSPN Name registered for this site or mobile facility *

Organisation name (if different to Trading Name)

ABN

Floor number and building name (where relevant)

Street number and name *

Suburb *

State *

Postcode *

Floor number and building name (where relevant)

Street number and name *

Suburb *

State *

Postcode *

Title *

First Name *

Last Name *

Position *

Telephone (work) *

Mobile

Facsimile (work)

Email Address (work) *

What type of imaging services does your practice provide under Medicare
(equipment used to provide these services must be registered to your LSPN)? * Angiography
Computed Tomography
Fluoroscopy
General X-ray
Mammography
Magnetic Resonance Imaging
Nuclear Medicine
Orthopantomography
Ultrasound

Which category does your practice fall into? *

New Practice Seeking Accreditation

Accredited Practice transferring from another accreditor

Previously accredited, but no longer

I am able to authorise and verify the information provided in respect to this application for accreditation.
I authorise NATA to verify the accuracy of the information provided in an application for accreditation by whatever means NATA sees fit.
I agree to:

notify NATA of significant changes to equipment, personnel or ownership of the LSPN within 28 days;
promptly pay all accreditation fees invoiced; and
be the primary contact at the LSPN for all accreditation related correspondence with NATA and the Department of Health.

I authorise NATA to store and use the information for the purposes of Division 5 of Part IIB of the HIA and the Legislative Instrument.
I am aware that giving false or misleading information is a serious offence.

I Agree

Full Name

Practice Contact Details

General

Address of physical location of practice OR the physical location of the base where the mobile equipment is located*

Postal address (Same as above )

Preferred Accreditation Contact

Practice Information

Thank you for registering your LSPN for DIAS accreditation with NATA.

Registration Failed

The registration has not completed successfully.

Please contact NATA DIAS Team on 03 9274 8200 for further assistance.