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 following these
instructions . - 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Failure to submit required documentation will result in a decision that the request has been voluntarily withdrawn.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 Immunology Anesthesiology - Burn (see General Surgery)
Cardiology Critical Care Medicine CVT Surgery (see General Surgery) Dentistry, General Dermatology Emergency Medicine Endocrinology Family Practice with and without OB Gastroenterology Hematology/Oncology Infectious Diseases Internal Medicine - Medical Toxicology (see Emergency Medicine)
Nephrology Neurology Neurosurgery Obstetrics & Gynecology - Occupational Medicine (see Family Medicine)
Ophthalmology Oral/Maxillofacial Surgery Orthopaedic Surgery Otolaryngology Pain Medicine Palliative Medicine Pathology Pediatrics Physical Medicine and Rehab (Physiatry) Plastic and Hand Surgery Podiatry Psychiatry Pulmonology Radiation Oncology Radiology, Diagnostic and Interventional Radiology, Emergency Coverage Rheumatology Surgery, General (includes Burn, CVT, Trauma) - Trauma (see General Surgery)
Urology
Other health care providers
Additional forms for physician assistants & nurse practitioners
Physician Assistants
You must submit a completed
Nurse Practitioners & Clinical Nurse Specialists
You must submit a completed