University Hospital
Forms:Medical Staff Office 

Medical Staff Office Forms

  • 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.
  • New applicants MUST select an application form, complete the Medical Information forms, and select at least one Delineation of Privileges form.
  • Documentation and Mandatory Education must be completed and returned to the Medical Staff Services department before an application can be considered complete.

Medical Information Form

  • Medical information is viewed only by the medical personnel in the Employee/Student Health.
  • Click here for PDF Medical Information forms.
  • All required medical information documents should be submitted at one time by mail or fax to:
    Employee/Student Health
    Upstate Medical University
    750 East Adams Street
    Syracuse, NY 13210

    (315) 464-5471

Application Forms

  1. Click on the form.
  2. It will open in Adobe Acrobat format (See below to learn more about Adobe, or to download).
  3. Click the print icon in Adobe (not on your browser).
  4. Complete the printed form.
  5. Sign the forms and return to:
    Medical Staff Office, CWB Room 204
    University Hospital
    750 E. Adams Street
    Syracuse, NY 13210

**PLEASE NOTE: A recent, recognizable photo is required before reference requests may be sent. Photos are stored in the applicant's file, and used for accurate identification purposes.

Delineation of Privilege Forms

Other Application Forms

Application Administrative link

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