APRN/PA Guidance on law changes 8.2024

Applicants:

If logged out after payment, email [email protected].

Licensee Alert: Scammers sending fake suspension notices

GCMB Issues Emergency Practice Permits for Hurricane Relief

Pain Management Clinic License forms

For questions about your Pain Management Clinic license or applying for Pain Management Clinic licensure, contact:

[email protected]

Cell: (404) 670-0662
Office: (404) 657-6494

HB178 - Law establishing the Pain Management Clinic License

Initial Application for Pain Clinic Licensure

General Information and Application Checklist (PDF, 356.97 KB)
Initial Application (PDF, 380.46 KB)
Form A - Affidavit of Applicant Owner (PDF, 39.23 KB)
Form B - Registration of Professional Business (PDF, 35.12 KB)
Form C - Hospitals Notification Form (PDF, 40.28 KB)

Change in Pain Clinic Ownership

General Information and Checklist
Change of Owner Application (PDF, 328.9 KB)
Form A- Affidavit of Applicant Owner (PDF, 39.23 KB)
Form B- Registration of Professional Business (PDF, 35.12 KB)
Form C- Hospitals Notification Form (PDF, 40.28 KB)
DELETE OWNER CHECKLIST (PDF, 104.86 KB)
DELETE OWNER APPLICATION (PDF, 259.23 KB)

To remove a owner from the pain clinic.

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
Application Form - Physician Assistant
General Information and Checklist - APRN
Application Form - APRN
Checklist and General Information - Managing Employee (PDF, 132.66 KB)

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