PA & AA Accordion
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New/Initial PA/AA Application Requirements
PLEASE
CLICK HERE FOR A SIMPLE CHECKLIST OF REQUIREMENTS FOR NEW GRAD PA/AA APPLICATIONS
Fee: $300
(Upload each PDF to your eGov application. If a third-party must send it, direct them to the GCMB NextRequest Portal — https://gcmb.nextrequest.com/. No physical mail.)
Requirements in Submission
Document Important Notes Initial Application (online) Complete in GCMB eGov portal; pay $300 fee at checkout. Form A – Affidavit (+ 2″×2″ photo) Notarized; applicant & notary dates match; label upload “FORM A”. Form A2 – Citizenship Affidavit Notarized; attach front + back of secure ID; upload “FORM A2”. Verifiable ID copy Driver’s license or passport; front + back; upload “ID”. Two Physician References – Form C (AA) or D (PA) Board-certified MD/DO; observed you ≤ 3 yrs; physician uploads via NextRequest; valid 6 months; cannot be your GA supervising MD. Certification Report – NCCAA/NCCPA Request agency send verification directly via email to [email protected]; must show current/pass status on letterhead. Form K – School Verification (or official transcript) PA/AA program sends; must bear registrar signature & seal; dates must match application. CV / Résumé Reverse-chronological; include clinical rotations; explain >30-month gaps. Add these to your submission only if applying with a supervising physician now
Document Key points PA/AA Utilization Form Indicates you’re applying with a supervisor; include GA MD license #. Basic Job Description – Form F (PA) / E (AA) Signed/dated by PA/AA (ID# “pending” ok) & supervising MD; list alternates on same form; e-signatures allowed. Form B – Request for Additional Duties If seeking Board approval for tasks beyond basic scope; 1 form per duty + case log as well as ACLS and BLS proof. Optional / Situational
- Form J – Specific Power of Attorney – authorize someone to talk to GCMB about your file.
- Form H – Separation Notification – used later, if/when you end a GA supervisory relationship.
Reminder: Applications are reviewed only after the $300 fee shows as paid and every mandatory upload is legible. Use the checklist PDF inside the accordion to double-check before you click “Submit”.
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Prior (Any State) PA/AA Application Requirements
PLEASE CLICK
HERE FOR SIMPLE CHECKLIST FOR PRIOR LICENSED PA/AA APPLICATION
Fee: $300
(Upload each PDF to your eGov application. Anything a third-party must send—references, state-license verifications, NCCPA/NCCAA letter, NPDB report—should be routed through the GCMB NextRequest Portal https://gcmb.nextrequest.com/. Please do not mail paper.)
Requirements in Submission
Required Documents Important Notes Application (online) Complete in eGov portal; pay $300 fee at checkout. Form A – Affidavit (+ 2″×2″ photo) Notarized; dates match; upload “FORM A”. Form A2 – Citizenship Affidavit & ID Notarized; attach front + back of ID; upload “FORM A2”. Verifiable ID copy Driver’s license or passport; front + back; upload “ID”. Two MD/DO References – Form C (AA) or D (PA) Observed you ≤ 3 yrs; physicians upload via NextRequest; valid 6 months; cannot be your GA supervising MD. NPDB Self-Query Report Applicant obtains; upload “NPDB”; include court docs if report shows “Yes”. NCCAA / NCCPA Verification Letter Request agency send verification directly via email to [email protected]; must show current/pass status on letterhead. Form K – Certificate of Education (or official transcript) PA/AA school sends; registrar seal/signature; dates match application. Current CV / Résumé Reverse-chronological; include rotations & gaps > 30 mo. Add these only if applying with a supervising physician now
Documents Important Notes PA/AA Utilization Form Indicates “with supervisor”; list GA MD license #. Basic Job Description – Form F (PA) / E (AA) Signed by PA/AA (“ID pending” ok) & MD; list alternates; e-signatures accepted. Form B – Request for Additional Duties 1 per extra duty; include case logs as well as ACLS and BLS proof. Optional / Situational
- Form J – Specific Power of Attorney – authorize a delegate to speak to GCMB about your file.
- Form H – Separation Notification – used later, if you end a GA supervisory relationship.
Check-before-submit: Confirm the $300 fee is paid, every mandatory file is clear, and all third-party uploads show as received in eGov before clicking “Submit”.
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Add/Change of Primary Supervising MD Application Requirements
PLEASE
CLICK HERE FOR ADD/CHANGE INFORMATION AND CHECKLIST DOCUMENT
Fee: $75
- Accepted Payment Options:
- Check
- Money Order
- PLEASE DO NOT MAIL CASH.
- Address:
- 2 MLK Jr Dr SE, East Tower 11th Floor, Atlanta GA 30334
- Include PA/AA name & license #.
- Approval follows receipt of payment.
(Submit everything through the GCMB NextRequest Portal https://gcmb.nextrequest.com/. Mail only the $75 check to GCMB with your name + license # and submit a photograph/copy of the payment with your NextRequest submission.)
Requirements in Submission
Document Important Notes Add/Change Supervising Physician Application Start a “PA/AA Add or Change Supervisor” request in NextRequest; upload the signed PDF. Basic Job Description – Form E (AA) / F (PA) e-signatures OK; PA/AA line may show “pending” ID; supervising MD lists all alternates and signs/date each page; label upload “FORM E” or “FORM F”. Optional / Situational
Document When needed Key notes Form B – Request for Additional Duties Requesting tasks beyond basic scope. One form per duty; include ≥10-case log & current ACLS/BLS. Form H – Separation Notification Ending a prior primary MD. PA/AA or former MD submits; states effective date. Form J – Specific Power of Attorney Delegate may speak to GCMB for you. Notarized; expires once change is approved. Checklist: Confirm the Application + BJD are uploaded, alternates are signed, and (if applicable) Form B/H/J are attached before submitting your NextRequest ticket.
- Accepted Payment Options:
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Reinstatement of PA/AA Licensure Application Requirements
PLEASE CLICK
HERE FOR OUR SIMPLE PA/AA REINSTATEMENT APPLICATION CHECKLIST
(Start a Reinstatement application in the eGov portal; choose Lapsed or Inactive status.
Upload your PDFs there. Any third-party documents—references, state license verifications, certification letters, NPDB—must come to GCMB via the NextRequest Portal https://gcmb.nextrequest.com/. No paper mail.)Requirements in Submission
Required document Key points (concise) Reinstatement Application (online) Select Lapsed → $400 fee or Inactive → $200 fee; pay in portal. Payment must include AA/PA’s name and GA license # for correct processing Form A – Affidavit (+ 2″×2″ photo) Notarized; dates match; upload “FORM A”. Form A2 – Citizenship Affidavit & ID Notarized; ID front + back; upload “FORM A2”. Verifiable ID copy Driver’s license/passport; front + back; upload “ID”. Two MD/DO References – Form C (AA) or D (PA) Observed you ≤ 3 yrs; physicians upload via NextRequest; valid 6 months; not your new GA supervisor. Certification Verification – NCCAA / NCCPA Request agency send verification directly via email to [email protected]; must show current/pass status on letterhead. CME Records Upload all CME earned since your last GA renewal. Current CV / Résumé Reverse-chronological; list gaps > 30 mo; include rotations if little recent practice. NPDB Self-Query Report Upload “NPDB”; attach court docs if report shows “Yes”. Add these only if reinstating with a supervising physician now
Document Key points PA/AA Utilization Form Indicates “with supervisor”; list GA MD license #. Basic Job Description – Form F (PA) / E (AA) Signed by PA/AA (“ID pending” ok) & new MD; list alternates; e-signatures accepted. Form B – Request for Additional Duties 1 per new duty; include ≥10-case log & ACLS/BLS proof. Optional / Situational
Document When needed Key notes Form J – Specific Power of Attorney Delegate may speak to GCMB. Notarized; expires once license reinstated. Form H – Separation Notification Closing a prior GA supervision. PA/AA or former MD submits; states effective date. Before you click “Submit”: verify the correct fee shows as paid, each required PDF is clear, and all third-party uploads (references, verifications, NPDB, certification letter) appear as received in your eGov checklist.
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All Forms and Checklists
CHECKLISTS
NEW
GRAD
PRIOR
LICENSED
ADD/CHANGE
REINSTATEMENT
ALL AVAILABLE FORMS
ADD
OR CHANGE SUPERVISING PHYSICIAN FORM
FORM A - Affidavit of Applicant
FORM
A2 - Citizenship Affidavit
FORM B
- Request for Additional Duties
FORM C
- Anesthesia Reference
(References are valid only for 6 months upon submission)
FORM D
- Primary Care Reference
(References are valid only for 6 months upon submission)
FORM E
- Anesthesia Basic Job Description
FORM F
- Primary Care Basic Job Description
FORM H
- SEPARATION NOTIFICATION
FORM
J - Specific Power of Attorney
FORM K
- Certificate of Education
PA/AA Utilization
Form
