Attending Physician Application and Forms

Initial Medical Staff Application

Physicians 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 the Medical Staff Services office at any time, by e-mail, fax, letter, or telephone call.

Staff Status Definitions (refer to these definitions when completing your application).

Forms

New applicants MUST complete an Initial Application form (available below as a PDF form) and at least one delineation form.

• Initial Application
• Medical/Clinical Privileges Delineation forms (Must select at least one)
• CBI
  Criminal Background Investigation (physician applicants not paid by the Research Foundation or State should print and complete this authorization form) Please note: Faculty being offered a paid position will receive this form from the Office of Faculty Affairs.
• Addendum (practitioners with more than one year of recent clinical inactivity)

Education

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

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

• Moderate Sedation
• C-Arm/Fluoroscopy
• CVP Education
• Impella Certification
: Education should be completed for the 'Impella 2.5' under the section labeled 'Automated Impella Controller'.
• Brain Death Certification

Application to the Medical Staff includes health clearance.

For applicants who will be obtaining a Faculty Appointment through the College of Medicine in addition to Medical Staff privileges, OR who are applying for Ambulatory Affiliate or Pediatric Courtesy status, this is done through Employee/Student Health.

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

For applicants who will NOT be requesting a Faculty Appointment through the College of Medicine AND whose Upstate University Hospital practice will be primarily at the Community Campus, this is done via the Associate Medical Director.

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