This government document is issued by Department of Community Health for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dch.georgia.gov/document/publication/157869879pchforms2010physiciansmedicalevalpdf/download&sa=U&ved=2ahUKEwii_fHWy5aHAxWW_bsIHdNlAXM4ChAWegQIBhAB&usg=AOvVaw3C13n-pY56TGP1GyTgFOhM&fexp=72519171,72519168