Form 100: what it is, who issues it and how to get it

What Form 100 is

Its official name is "Certificate of health status", Form IV-100/a (ფორმა IV-100/ა). It is a record form approved by the Ministry of Health, through which a medical facility informs a third party of the patient's diagnosis, the treatment given and the recommendations. This "for a third party" is exactly what sets it apart from a discharge summary (epicrisis): the discharge summary is a doctor's internal document describing the course of treatment for another doctor, whereas Form 100 is a summary read by an agency, an employer, an insurance company or a court.

A common misunderstanding: Form 100 is not Form 50 (the laboratory test form), and it is not a "sick note" (a certificate of temporary incapacity for work). If an agency has asked for Form 100, no other document can replace it.

What it must contain: the fields the recipient checks

1. The facility's details: name, address, identification code, letterhead or stamp.
2. Certificate number and date of issue. A certificate without a date is not valid.
3. Patient details: first name, surname, date of birth, personal number, address. The surname exactly as on the ID card.
4. Diagnosis in words and with an ICD-10 code. Without the code, the agency cannot establish whether the case falls under a programme.
5. Medical history and tests carried out, briefly: when it started and which tests confirmed it.
6. Treatment given and current condition.
7. Recommendation stating a specific intervention, treatment or regimen. The phrase "requires treatment" is not enough; it needs to say "[name of the operation] is recommended".
8. Purpose: "for submission as required" or a specific addressee. Some agencies ask for their own name.
9. The doctor's name, position, signature and personal stamp, as well as the facility's stamp. Both stamps must be legible.

Who issues it and how

Form 100 is issued by the facility where the patient is under observation or treatment: a family doctor or polyclinic for outpatient cases, a hospital after discharge, a private clinic or diagnostic centre within its competence. The certificate is signed by the treating doctor and, in some facilities, also by the head of the facility.

How to request it

• Go to the reception desk or your treating doctor and say who the certificate is for. The doctor fills in the text differently depending on the purpose.
• If you need it to fund an operation, ask for the specific intervention and its urgency to be stated in the recommendation.
• If the medical record is closed, the certificate is prepared from the archive, which takes several days.
• Some facilities print the certificate from an electronic system: such a certificate should carry a QR code or an electronic number that the recipient uses to check that it is genuine.
• The certificate may be free or paid, depending on the facility's rules. Keep the receipt.

How long it is valid

The law sets no validity period for Form 100: the certificate reflects the patient's condition on the day of issue. The period is set by the recipient, and the logic is simple: the faster the condition changes, the more recent the certificate needs to be. In practice:

• Up to 1 month: City Hall and Ministry commissions, embassies for visas, insurance companies.
• Up to 3 months: foreign clinics for a cost estimate, employers, educational institutions.
• Up to 6 months: courts and notaries, if the certificate confirms the fact of a condition rather than a current need.

If you are submitting the certificate to several agencies, time it with the order of your applications in mind, bring a certified copy everywhere and keep the original.

Who needs what: one certificate, different expectations

8 reasons a certificate is rejected

1. There is no ICD-10 code, or only a group code without the subcategory.
2. The recommendation is vague: "requires observation", "treatment is recommended" without naming the intervention.
3. The stamp is illegible, or there is one stamp instead of two (the doctor's personal stamp and the facility's).
4. The surname differs from the ID card by one letter, or the personal number is wrong.
5. Handwritten corrections in the text without a signature and stamp next to them.
6. The date is too old for a recipient that has set a one-month limit.
7. An uncertified copy where the original or a notarised copy is required.
8. The wrong form: a discharge summary, an extract or Form 50 instead of Form 100.

Translation, notary, apostille: which one and when

A Form 100 issued in Georgian is valid abroad only in translation. There are three levels, and the choice depends on the recipient:

• A standard translation is enough for a clinic preparing a cost estimate or for a doctor giving a second opinion. What matters most is terminological accuracy, because the clinic builds its plan on this text.
• A notarised translation is needed by an embassy, an insurance company, a foreign foundation and any clinic that signs a formal contract. How it is prepared and what it costs is on the medical translation page.
• An apostille is added when you submit Form 100 to a state body or court in another country, or when an embassy asks for it for a visa. A clinic's certificate is a document of a medical facility and can be apostilled directly, and if the recipient also needs a translation, the apostille is placed on the notarised translation as well. Details are on the apostille and legalisation page.

Within Georgia, for funding applications, no translation is needed, but the content of the certificate decides the fate of the application. What Form 100 must say for the commission to calculate the amount is explained in the guide to funding for surgery, and if you are refused, a legal consultation will help.