Pain Management Clinic License Forms

* Please visit https://gateway.medicalboard.georgia.gov/** to register with our new licensing gateway in order to access your license page. Your old credentials will not work, you must register first. Here is an instruction guide:

licensing infrographic 1.pdf (PDF, 4.21 MB)

For questions about your Pain Management Clinic license, submit a request here: NextRequest

Initial Application for Pain Clinic Licensure
To Apply, Click Here: https://gateway.medicalboard.georgia.gov/
- Affidavit of Applicant Owner (PDF, 39.23 KB)
- Citizenship Affidavit (PDF, 308.53 KB)
- Registration of Professional Business (PDF, 35.12 KB)
- Hospitals Notification Form (PDF, 40.28 KB)
- Personnel Certification Form (PDF, 237.44 KB)
Renewal Application for Pain Clinic Licensure
To Renew, Click Here: https://gateway.medicalboard.georgia.gov/
- Pain Mgmt Clinic Renewal Pmt Cover Letter (PDF, 166.25 KB)
- Citizenship Affidavit (PDF, 308.53 KB)
- Personnel Certification Form (PDF, 237.44 KB)
Change in Pain Clinic Ownership
To Apply, Click Here: https://gateway.medicalboard.georgia.gov/
Forms
- Affidavit of Applicant Owner (PDF, 39.23 KB)
- Registration of Professional Business (PDF, 35.12 KB)
- Hospitals Notification Form (PDF, 40.28 KB)
- Personnel Certification Form (PDF, 237.44 KB)
Request to Add, Delete, Edit or Revise Pain Clinic Information
General Information & Checklist - Practicing Physician (PDF, 153.22 KB)
- Application Form - Practicing Physician (PDF, 218.11 KB)
General Information and Checklist - Physician Assistant (PDF, 212.55 KB)
- Application Form - Physician Assistant (PDF, 289.97 KB)
General Information and Checklist - APRN
- Application Form - APRN (PDF, 175.99 KB)
Checklist and General Information - Managing Employee (PDF, 132.66 KB)

HB178 - Law establishing the Pain Management Clinic License (PDF, 26.52 KB)

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