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, please click on Application and click 'Request Account'.

Application External Icon

Forms

Required Education (Complete all of the below):

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. External Icon

Required Health Forms:

Please download and complete: Medical Information forms. PDF Icon
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