ADD/CHANGE OF PRIMARY SUPERVISING MD

PLEASE CLICK HERE FOR ADD/CHANGE INFORMATION AND CHECKLIST DOCUMENT

Here is where you submit your application and supporting documents:

Our NextRequest Portal: GCMB Requests Portal NextRequest - Modern FOIA & Public Records Request Software

APPLICATIONS WILL NOT BE REVIEWED WITHOUT APPLICATION FEE OF $75.00

Mail Payment To:
2 Martin Luther King Jr. Drive SE East Tower, 11th Floor
Atlanta, GA 30334 US

Payment must include AA/PA’s name and GA license # for correct processing

AVAILABLE FORMS TO DOWNLOAD (YOU MAY NOT NEED ALL OF THESE, PLEASE REFER TO CHECKLIST)

ADD OR CHANGE SUPERVISING PHYSICIAN FORM

ADDITIONAL DUTY REQUEST FORM CHECKLIST

FORM B - REQUEST FOR ADDITIONAL DUTIES

FORM H - SEPARATION NOTIFICATION

FORM J - Specific Power of Attorney