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Privilege forms

If you are applying for the first time, please follow these instructions:

  1. Scroll down to find the appropriate privilege form for your specialty.
  2. Open the privileges by clicking on specialty title.
  3. Print and complete the privileges PDF form by putting a checkmark or “X” where indicated for the desired core privileges and special request privileges.
  4. Check only the privileges for which you wish to apply.
  5. Provide complete contact information for references.
  6. If documentation of cases or procedures is required, attach case or procedural logs to your privilege delineation.
  7. 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Failure to submit required documentation will result in a decision that the request has been voluntarily withdrawn.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 & dentists

Other health care providers

Additional forms for physician assistants & nurse practitioners

Physician Assistants

You must submit a completed Notice of Intent to Practice Form and Delegation Agreement along with your application.

Nurse Practitioners & Clinical Nurse Specialists

You must submit a completed Advanced Practice Registered Nurse Prescriptive Agreement along with your application.