Document ID: chunk:federal_register_of_legislation:F2017L01293:clause:2_12:p3
Version: federal_register_of_legislation:F2017L01293
Segment Type: clause
Provision Reference: sch 2 cl 12 (pt 3/3)
Character Range: 25184–26582

to services (and associated equipment for those services) as detailed in this Part. These services will be updated from time to time in consultation with the Royal College of Pathologists Australasia.

       * Blood gas analysis
       * Haemoglobin Ometer
       * Glucose Reading

Part 5—Execution of undertaking

I ____________________________________________________
(full name in  block letters)

a medical practitioner who is or wishes to become an approved pathology practitioner, hereby give the undertaking recorded in this Schedule. I acknowledge that a breach of this undertaking may be referred to a Medicare Participation Review Committee (MPRC) in accordance with the Act and, pursuant to section 124FB of the Act, the MPRC may make a number of determinations including that Medicare benefits should not be payable for up to 5 years.

I request the Minister or a delegate of the Minister to accept the undertaking under section 23DC of the Act. I certify that all information in this application is true and correct.

Signature:

Date:

Address:

Witness (see 'Applicant Instructions' for detail on witness requirements & execution of undertaking)

I, ______________________, hereby assert that the applicant is known to me or, if not known, am satisfied as to her/his identity, and did witness the signing of this instrument before me on this day.

Signature:

Date:

Address: