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


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

  • Moderate Sedation
  • CVP Education PDF document
  • Return above forms to:

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

    Application includes health clearance.

    Please download and complete: Medical Information forms. PDF document
    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
    Employee/Student Health
    750 East Adams Street
    Syracuse, NY 13210
    Fax: (315) 464-5471