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.
New applicants MUST complete the initial application and privilege forms; if you have not received an invitation, e-mail email@example.com with your name, specialty, and e-mail address.
- Hand Stamp request form
- 4NP form (for newly graduated Nurse Practitioners only)
- Practice Agreement (NP only)
- PA Supervisory form (PA only)
- CBI (Applicants being hired through MedBest or a private office should print and complete this authorization form)
Required Education (Complete all of the below):
- Title IX, Clery Act & Sexual Harassment Prevention Training
- Credentialed Provider Mandatory Education
- Confidentiality Agreement
- Credentialed Provider Orientation
- Fire Safety in the OR
For your convenience (if you have not already submitted a current certificate):
If requesting special privileges, complete the appropriate education or form (s):
* Signed documents may be uploaded to your application using the MD-App Application or faxed to 315-464-8524.
Required Health Forms:
Please download and complete: Medical Information forms.
Documents are viewed only by the medical personnel in the Employee/Student Health offices and should be submitted at one time by mail or fax to:
Upstate Medical University
750 East Adams Street
Syracuse, NY 13210
Fax: (315) 464-5471