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Failure to submit required documentation will result in a decision that the request has been voluntarily withdrawn.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
Other health care providers
Additional forms for physician assistants & nurse practitioners
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.