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Privilege Forms
If you are applying for the first time, please follow these instructions:
- Scroll down to find the appropriate privilege form for your specialty.
- Open the privileges by clicking on specialty title.
- Print out and complete the PDF form by putting a checkmark or "X" where indicated for the desired core privileges and special request privileges.
- Provide complete names and addresses, phone and fax numbers for references.
- If documentation of cases or procedures is required, attach case or procedural logs to your privilege delineation.
- Check only the privileges for which you wish to apply.
- Sign and date where indicated.
Failure to submit required documentation will result in a decision that the request has been voluntarily withdrawn.
Delineation of Privileges
For Physicians, Podiatrists and Dentists
All Other Health care Providers
Additional Forms for Phyician Assistants and Nurse Practitioners
Physician Assistants
You must submit a completed Notice of Intent to Practice Form and Delegation Agreement along with your application.
Nurse Practioners and Clinical Nurse Specialists
You must submit a completed Advanced Practice Registered Nurse Prescriptive Agreement along with your application.
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Conscious Sedation
Regions Hospital requires specific privileges for conscious (i.e., moderate) sedation. Privileges for Conscious Sedation may be requested by completing the Conscious Sedation test and returning it with your initial credentialing documents If you feel you need a refresher, contact Medical Staff Services for the study module.
Conscious Sedation Test
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