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
- 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)
- Credentialed Provider Mandatory Education
- Infection Control
- Confidentiality Agreement
- Procedure Verification
If requesting special privileges, download and complete the appropriate forms:
Return above forms to:
Medical Staff Services
750 E. Adams Street
Syracuse, NY 13210
Application includes health clearance.
For applicants who will be working primarily at the Downtown campus, or who are State employees:
Please download and complete: Downtown Campus
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
For applicants whose Upstate University Hospital practice will be primarily at the UUH at Community Campus:
Please download and complete: UUH at Community Campus Medical Information forms.
Documents are reviewed by the Associate Medical Director and should be submitted at one time by mail or fax to:
Associate Medical Director
4900 Broad Road
Syracuse, NY 13215
Fax: (315) 464-8524