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Medical Staff Delineation of Privileges PDF document

For the following privileges, separate documentation is required:

  • C_Arm / Fluoroscopy Privileges
  • Moderate (Conscious) Sedation Packet for Providers

Please select, print, and request privileges from the appropriate form listed below:

  • Anesthesiology
  • Cardiopulmonary (Dept. of Surgery)
  • Cardiovascular Electrophysiology
  • Critical Care Medicine
  • Dental Surgery
  • Emergency Medicine
  • Emergency Medicine: Minor Treatment / Urgent Care Area
  • Endoscopy
  • Family Medical Practice
  • Internal Medicine
  • Neurocritical Care: Attending
  • Neurocritical Care: Fellow
  • Neurosurgery
  • Neurology
  • Obstetrics/ Gynecology
  • Ophthalmology
  • Orthopedics
  • Otolaryngology
  • Pathology
  • Pediatrics
  • Peripheral Vascular Intervention (Addendum to Surgery, Radiology, & Invasive Cardiology Privileges forms)
  • Podiatry
  • Psychiatry
  • Physical Medicine and Rehabilitation
  • Radiology
  • Radiation Oncology
  • Renal Dialysis
  • Plastic Surgery
  • General Surgery
  • Thoracic Surgery (Addendum to General Surgery form)
  • Urology

Privilege forms and supporting documentation can be sent to Medical Staff Services via fax [(315) 464-8524], or directly to the Credentialing Coordinator processing your application.

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Last Modified: Jan 28, 2013. Contact Beth Erwin with questions about the content of this page.
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