Georgia Department of Community Health
Healthcare Facility Regulation Division (HFRD)

This form is to be completed by the individual petitioner of the appeal or their legal representative.

Please provide the requested information to appeal an Unsatisfactory GCHEXS Determination.

Your employer can provide your Background Check #
Phone Number
Mailing Address
Do you have an attorney representing you for this appeal?
Your Attorney's Name
Your Attorney's Phone Number
Your Attorney's Mailing Address

Please list all disqualifying offense(s) you are appealing. The offense(s) are listed on the applicant unsatisfactory letter. If you do not have a copy of the letter, please email [email protected].

Re-order Offense Date Weight Operations
more items
Upload a copy of your certified arrest/court documentation or a signed and notarized statement from the petitioner which includes the following:

  • Describe the facts and circumstances around the arrest.
  • Was anyone harmed in the commission of the crime?
  • What was your sentence? When were you released from jail and/or probation/parole?
One file only.
256 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
Verify Information is Correct
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