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Diagnostic Imaging – Change of Practice Details

Diagnostic Imaging - Change of Practice Details

Please use the form below to submit any changes to your diagnostic imaging practice details. Select the tick box of the relevant option(s) and complete the fields below.

"*" indicates required fields

Client ID:*

Please provide your QIP Diagnostic Imaging Client ID. E.g. DI7044

Organisation Name:*

Please provide your organisation name as currently registered with QIP.

ABN:*

Please provide your 11-digit number Australian Business Number (ABN)

Opening Date:*

Please provide the date your practice opened or changed ownership.

Details to be changed

Please select the option(s) of the details that you would like to change and complete any information to support as prompted.

Change of Ownership

Change of organisation ownership

File*

Please provide a letter from the previous owner confirming sale of the organisation

Accepted file types: pdf, Max. file size: 50 MB.

Change of Organisation Name

Change of organisation name

Current organisation name

Please enter your current organisation name:

New organisation name

Please enter your new organisation name:

Change of accreditation contact details

Current preferred accreditation contact details

First Last

Phone

Website

Fax

New preferred accreditation contact details

First Last

Phone

Website

Fax

Change of corporate entity details

Current corporate entity details

Please provide current corporate entity details:

New corporate entity details

Please provide new corporate entity details:

Change of Location Specific Practice Number (LSPN)

Current LSPN

Please provide current LSPN:

New LSPN

Please provide new LSPN:

Change of address

Change of Address

Current Street Address

Street Address Address Line 2 City State/Territory Postcode

New Street Address

Street Address Address Line 2 City State/Territory Postcode

Change of postal address

Please select if postal address is different to street address

Current Postal Address

Postal address Address Line 2 City State/Territory Postcode

New Postal Address

Postal address Address Line 2 City State/Territory Postcode

Reason for change(s)

Please tick the following that relate to any changes to your organisation:

Your organisation is currently going through or has gone through a merger or change of ownership

Aspects to your service provision have changed i.e. services provided

Changes to staff members

Your organisation is adhering to different policies and procedures

Authorisation

Please provide your name, signature and date as authorisation of change of details:

Name*

First Last

Date*

MM slash DD slash YYYY

Signature*

Name

This field is for validation purposes and should be left unchanged.

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Home
What is accreditation?
Standards
Find the right accreditation
Resources & support
For consumers
Contact us

Navigate

Home
What is accreditation?
Standards
Find the right accreditation
Resources & support
For consumers
Contact us

Navigate

Home
What is accreditation?
Standards
Find the right accreditation
Resources & support
For consumers
Contact us

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