APRN Protocol Registration Forms

Please Review Our Application Checklist and Checkout the Examples!

1. APRN Application Checklist - Get Your Application Reviewed the First Time!

2. APRN Registration Form and Protocol Agreement

EXAMPLE APRN Registration Form and Protocol Agreement

3. FORM A - Designated Physician Information

EXAMPLE Form A

4. FORM B - Protocol Agreement Termination

EXAMPLE Form B

5. FORM C - Protocol Agreement Worksheet

EXAMPLE Form C

6. APRN Amendment – Radiographic Imaging Tests

7. APRN Amendment – Limited CII and Death Certificates

Click HERE for information on all protocol agreements that have been received and reviewed by the Board.

Any outstanding documents for APRN protocol should be sent to our office email address listed below:

**** [email protected] *****

Please provide the applicants full name in the email subject line.

Important Information about the Delegating Physician's Location

A delegating physician in Georgia must have an active state license and practice within the state or within 50 miles of where the patient is located when receiving services. This applies to both in-person and telehealth services provided by an APRN and is independent of the business model.

APRN Protocol Review Simplified:

Most APRN protocols are approved without the need for review by the APRN Committee or the full Board, known as administrative approval. However, protocols may require further review if they present “red flags,” such as:

• Disciplinary actions on the APRN’s or physician’s license.
• A mismatch in specialties between the APRN and the delegating physician.
• Use of a non-standard protocol agreement by the APRN.
• Procedures listed in Form-C that are outside the APRN’s specialty.

If a protocol meets all statutory requirements and is free of red flags, it will be administratively approved, and an approval letter will be issued. This letter is crucial for subsequent credentialing steps, like DEA registration and hospital privileges. APRNs are advised to wait for this approval before applying for DEA privileges.

The processing time for protocol approval varies, ranging from a few weeks to months, depending on the application’s completeness. To expedite approval, it’s best to submit correct and complete documentation initially. Quick responses to Board staff communications can also reduce processing times.