Health Professionals Application and Forms

All applicants, as part of the credentialing and privileging process, must successfully complete a Criminal Background Investigation.

Practitioners applying for privileges have the right to review their application after submission, and correct an errors on the application. Applicants may request information on the status of their application from Medical Staff Services at any time, by e-mail, fax, letter, or telephone call.

Initial Application Forms

• Application
• Privilege Delineation forms (All applicants must select at least one)
• 4NP form (for newly graduated Nurse Practitioners only)
• Practice Agreement (NP only)
• CBI (Applicants being hired through MedBest should print and complete this authorization form)

Education

• Infection Control
• Safety at Work
• HIPAA/Confidentiality Agreement

If requesting special privileges, download and complete the appropriate forms:

• Moderate Sedation

Return above forms to:

Upstate Medical University
Medical Staff Services
Suite 1100
750 E. Adams Street
Syracuse, NY 13210
Fax: 315-464-8524

Health

• Medical Information Forms

Return Medical Information forms to:

Upstate Medical University
Employee/Student Health
750 East Adams Street
Syracuse, NY 13210
Fax: (315) 464-5471