Health Professionals Application and Forms

All applicants, as part of the credentialing and privileging process, must successfully complete a Criminal Background Investigation.

Practitioners applying for privileges have the right to review their application after submission, and correct an errors on the application. Applicants may request information on the status of their application from Medical Staff Services at any time, by e-mail, fax, letter, or telephone call.

Initial Application Forms

Education

If requesting special privileges, download and complete the appropriate forms:

  • Moderate Sedation
  • CVP Education PDF document
  • Return above forms to:

    Upstate Medical University
    Medical Staff Services
    Suite 1100
    750 E. Adams Street
    Syracuse, NY 13210
    Fax: 315-464-8524

    Application includes health clearance.

    For applicants who will be working primarily at the Downtown campus, or who are State employees:

    Please download and complete: Downtown Campus Medical Information forms. PDF document
    Documents are viewed only by the medical personnel in the Employee/Student Health offices and should be submitted at one time by mail or fax to:

    Upstate Medical University
    Employee/Student Health
    750 East Adams Street
    Syracuse, NY 13210
    Fax: (315) 464-5471

    For applicants whose Upstate University Hospital practice will be primarily at the UUH at Community Campus:

    Please download and complete: UUH at Community Campus Medical Information forms. PDF document
    Documents are reviewed by the Associate Medical Director and should be submitted at one time by mail or fax to:

    Associate Medical Director
    4900 Broad Road
    Syracuse, NY 13215
    Fax: (315) 464-8524

    If you are not certain which of the Medical Information forms to use, please contact Medical Staff Services at (315) 464-5733.