Attending Physician Application and Forms

Initial Medical Staff Application

Physicians 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 the Medical Staff Services office at any time, by e-mail, fax, letter, or telephone call.

Staff Status Definitions (refer to these definitions when completing your application).


New applicants MUST complete an Initial Application form (available below as a PDF form) and at least one delineation form.

Documents above should be sent to:

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


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

Application to the Medical Staff includes health clearance.

Please download and complete: 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