Applicants:

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

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
Initial Application	Form A - Affidavit of Applicant Owner	Form B - Registration of Professional Business	Form C - Hospitals Notification Form

Renewal Application for Pain Clinic Licensure
General Information and Checklist
Pain Mgmt Clinic Renewal Pmt Cover Letter
Renewal Application Packet	Form B - Pain Mgmt Clinic - Citizenship Affidavit

Change in Pain Clinic Ownership
General Information and Checklist
Change of Owner Application	DELETE OWNER CHECKLIST	DELETE OWNER APPLICATION
Form A- Affidavit of Applicant Owner	Form B- Registration of Professional Business	Form C- Hospitals Notification Form

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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