An official website of the State of Georgia government.
Here’s how you know
State government websites often end in .gov. Before sharing sensitive information, make sure you’re on a state website. Still not sure? Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia.
The https:// ensures that any information you provide is encrypted and transmitted securely.
The following forms should be completed when applying for licensure as an Institutional Physician:
General Information and Checklist
Initial Application for Institutional License
FORM A - Exceptional Circumstances
FORM B - Certificate of Post Graduate Training
FORM C - Reference Form
FORM D - State Verification
FORM E - Termination Form
FORM F - Specific Power of Attorney