This government document is issued by Composite Medical Board for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://medicalboard.georgia.gov/document/form-designated-physician-information/download&sa=U&ved=2ahUKEwia5s_WipmHAxUzhv0HHVOSCig4KBAWegQICRAB&usg=AOvVaw11ZD2wC1XDaC-WRzHvOxv2&fexp=72519171,72519168