Form ac1 pa adding alternate physicians form fillable 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Primary Sponsoring Physician’s Name, followed by their signature and license number. Ensure all details are accurate.
  3. Fill in the Practice Address and the Physician Assistant's name, including their first, middle, and last names along with their license number.
  4. The PA must sign and date the form in the designated areas provided.
  5. For each alternate physician, complete every line with their name, license number, signature, and date signed. Remember that all fields must be filled; otherwise, your submission may be returned.
  6. Once completed, save a copy for your records and ensure a copy is provided to the PA before submission.
  7. Finally, return this form to the Georgia Composite Medical Board at the specified address.

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