Physician

o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.
o    This form is optional and should be submitted if you want an agency or other individuals who you designate to assist with your application (all hospitals, employers, recruiters, referral companies, or family members)
o    Applications are confidential pursuant to State law, which is why the Board requires this form before sharing application information/updates
o    Should be attached in emails sent by credentialing agent/agency with recognizable notary seal
o    Include contact information of the third party
o    Must be signed by applicant and notarized

o    HOW TO SUBMIT: The Board no longer accepts paper applications.  All applications should be submitted through the Board's online portal.
o    Answer all questions honestly and thoroughly
o    Some “Yes” responses require statements of the circumstances surrounding the event and relevant documentation to the situation.  If an answer requires an explanation or additional supporting documentation (court records, board actions, etc.), it can be uploaded via the online portal.
o      Click HERE to download the step-by-step walkthrough for assistance with submitting an online application

o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.
o    Read this form in its entirety and complete all areas
o    A current passport photo is required to complete this form
o    Do not submit photos from digital reproductions, magazine, yearbook, wedding, birthday, family outing, etc.
o    Color copy best to ensure readable photo and notary
o    Photo has to recognizable
o    Take this form to a notary public for witness of your signature and their notarization
o    Notary Seal must be recognizable via scanned email
o    The applicant’s signature date and the notary signature date must match
o    No whiteouts or strikeouts are accepted

o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.
o    Take this form to a notary public for witness of your signature and their notarization
o    The applicant’s signature date and the notary signature date must match
o    Notary Seal must be recognizable via scanned email
o    No whiteouts or strikeouts are accepted

o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.

US Citizens
o    Clear, legible copy of Driver’s license or Passport.  Only one document is required.
o    Please avoid use of Birth Certificates as they are required by law to be an original or certified copy of the original

Non-U.S. Citizens
o    Clear, Legible copy of qualified alien status documents, i.e.  Permanent Resident Card – front and back; SEVIS document; etc.
o    Please avoid copies of Driver’s license as this does not indicate your citizenship status in the U.S.
o    The Board participates in the DHS-USCIS SAVE (Systematic Alien Verification for Entitlements or "SAVE") program for the purpose of verifying citizenship and immigration status information of non-citizens
o    In order to confirm your status with the SAVE program, you need to provide the board with legible copies of one of the verifiable documents listed
o    If the following information is needed, it must be legible: Alien Number; Card Number; Document Expiration Date; SEVIS ID Number
o    One or all of these numbers or dates may be required when we submit your information to SAVE
o    If we cannot read what you have submitted, we will be unable to submit your information to the SAVE program, which will delay the consideration of your application

Malpractice Questionnaire Form
o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.
o    Required of all applicants
o    All areas are to be completed as applicable
o    Check “None” box if you have never been named in a malpractice case
o    If named in a suit, include all information for the case
o    This form should be signed and dated
o    This form does NOT require notarization
o    Complete a form for each malpractice case in which you have been named, regardless of the disposition
 

Malpractice Documentation
o    HOW TO SUBMIT: Upload this document into the online account at the time of application submission.
o    ONLY required if you have been named in a malpractice case
o    Compile all malpractice documentation into ONE document for each case
o    Documentation for each case reported should include: (1) Malpractice Questionnaire Form, (2) Personal Narrative, (3) Plaintiff’s Complaint, (4) Summary Judgment, Voluntary Dismissal, Dismissal Order, etc.

o    HOW TO SUBMIT: This document must come directly from your GME program (unless noted below).  This document is NOT accepted from the applicant or credentialing agent/agency.
o    Can be included as part of the FCVS profile sent to the Board by FSMB.  FCVS notifies the applicant when the Physician Profile has been sent to the Georgia Composite Medical Board. Please follow up with Board staff once the FCVS report has been released.  More info:  https://www.fsmb.org/fcvs
o    All institutional Seals and/or Notary Stamps must be recognizable
o    Graduates from Board-approved medical schools are only required to complete ONE year of ACGME training
o    Graduates from non-Board-approved medical schools are required to complete THREE years of ACGME training.  Documentation MUST reflect that three years have been completed.
o    The Board's approved medical school/international medical graduate policy: https://medicalboard.georgia.gov/international-medical-graduate-policy-022010

o    HOW TO SUBMIT: This document must come directly from the physician giving the reference.  This document is NOT accepted from the applicant, credentialing agent/agency, or the reference's practice manager/assistant.  This document is NOT accepted from a reference's personal email address such as Gmail, Yahoo, Hotmail, etc. and is required to be sent from a reference's business email address (hospital, school, practice, clinic, etc.).
o    Three references are required for Initial Licensure
o    Two references are required for Reinstatement
o    Reference must be from a licensed physician who has been familiar with your practice for at least six months
o    Reference must sign and date the form
o    Forms are valid for six months