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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 and complete the privileges PDF form by putting a checkmark or “X” where indicated for the desired core privileges and special request privileges.
- Check only the privileges for which you wish to apply.
- Provide complete contact information for references.
- If documentation of cases or procedures is required, attach case or procedural logs to your privilege delineation.
- 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Failure to submit required documentation will result in a decision that the request has been voluntarily withdrawn.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
- Allergy and Immunization
- Burn (see General Surgery)
- CVT Surgery (see General Surgery)
- Dentistry, General
- Emergency Medicine
- Family Practice with and without OB
- Infectious Diseases
- Internal Medicine
- Medical Toxicology (see Emergency Medicine)
- Obstetrics & Gynecology
- Occupational Medicine (see Family Medicine)
- Oral/Maxillofacial Surgery
- Orthopaedic Surgery
- Pain Medicine
- Palliative Medicine
- Physical Medicine and Rehab (Physiatry)
- Plastic and Hand Surgery
- Pulmonology/Critical Care Medicine
- Radiation Therapy
- Radiology, Diagnostic and Interventional
- Radiology, Emergency Coverage
- Surgery, General (includes Burn, CVT, Trauma)
- Trauma (see General Surgery)
Other health care providers
- Certified Nurse Midwife (CNM)
- Certified Nurse Anesthetist (CRNA)
- Clinical Nurse Specialist (CNS)
- Nurse Practitioner (NP)
- Physician Assistant (PA-C)
- Physician Assistant (Emergency Medicine)
- Psychologist, Licensed (LP)
- Licensed Independent Clinical Social Worker
- Registered Nurse Clinician
- Registered Dental Assistant
- Surgical Assistant
Additional forms for physician assistants & nurse practitioners
Nurse Practitioners & Clinical Nurse Specialists
You must submit a completed Advanced Practice Registered Nurse Prescriptive Agreement along with your application.