APRN Protocol Registration Forms

Please find below the complete application and additional forms needed to submit an APRN Protocol Agreement registration.


Download this pdf file. APRN Protocol Agreement (use this form to expedite the protocol review)

Download this pdf file. APRN Amendment

Download this pdf file. APRN Registration Form

Download this pdf file. FORM A - Designated Physician Information

Download this pdf file. FORM B - Protocol Agreement Termination

Download this pdf file. FORM C - Protocol Agreement Worksheet (v2023-09)

Click HERE for information on all protocol agreements that have been received and reviewed by the Board.


Any outstanding documents for APRN protocol should be sent to our office email address listed below:

**** [email protected] *****

Please provide the applicants full name in the email subject line. 


Important Information about the Delegating Physician's Location

A delegating physician must hold an active Georgia physician license, practice medicine in Georgia, and either the physician’s principal place of practice is located within Georgia or outside of Georgia but is within 50 miles from the location where the protocol is being utilized.  “Where the protocol is being utilized” is the physical location of the patient at the time services are rendered.  If the APRN is providing telehealth services, the delegating physician must still meet all the above requirements. These requirements do not change based on business model.


Helpful Context about the APRN Protocol Review Process

APRN protocols can vary on how they are processed.  Most protocols are NOT reviewed by the APRN Committee and full Board, but rather, they are approved administratively.  The Board, through its APRN Committee, only reviews protocols with “red flags.”  Here are some of the common items that will require an additional review by the Board’s APRN Committee (including but not limited to):

  • If the APRN or delegating physician has discipline on their license
  • If the APRN has a different specialty from the delegating physician
  • If the APRN uses their own protocol agreement (instead of the Board’s current protocol template)
  • If the APRN has a Form-C with procedures outside of their specialty

The majority of protocols are administratively approved and do not need to go to the Board.  If the protocol agreement meets all requirements set forth in the statute and there are no red flags, then Board staff will administratively approve the protocol and issue an approval letter.  That approval letter is important for next steps in the credentialing process (DEA, hospital privileges, etc.).  It is strongly suggested that an APRN not apply for DEA privileges until the protocol agreement is approved by the Board.

For a timeframe, it varies by the application and the completeness of the file.  It can take as short as couple weeks or as long as a few months.  Best practice would be to submit the correct documentation the first time.  Only about 15% of the protocols the Board receives are actually “complete.”  The Board usually needs additional documentation that was not initially submitted, or the protocol agreement was not filled out fully or was filled out incorrectly.  Additionally, responding quickly to emails from Board staff can shorten processing time.


For questions regarding your APRN Protocol agreement and any supporting documentation, please contact the correct specialist.



Licensure Specialist Jazzmine Daniel

Contact for APRN protocol applicants with last names A - I


Licensure Specialist

Contact for APRN protocol applicants with last names J - R


Licensure Specialist Sherine Orrigio

Contact for APRN protocol applicants with last names S - Z