Pain Management Clinic License forms

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

contact:

Contact Application Specialist

Tara Edwards

Primary:

(404) 463-2292

tara.edwards@dch.ga.gov

HB178 - Law establishing the Pain Management Clinic License

Initial Application for Pain Clinic Licensure

General Information and Application Checklist (212.6 KB)

Initial Application (332.47 KB)

Form A - Affidavit of Applicant Owner (39.23 KB)

Form B - Registration of Professional Business (35.12 KB)

Form C - Hospitals Notification Form (40.28 KB)

Change in Pain Clinic Ownership

General Information and Checklist (203.08 KB)

Change of Owner Application (295.59 KB)

Form A- Affidavit of Applicant Owner (39.23 KB)

Form B- Registration of Professional Business (35.12 KB)

Form C- Hospitals Notification Form (40.28 KB)

Request to Add, Delete, Edit or Revise Pain Clinic Information

General Information & Checklist - Practicing Physician (153.22 KB)

Application Form - Practicing Physician (218.11 KB)

Professional Resources