Forms:Medical Staff Services

Medical Staff Services Department Forms

Return all forms to:
Medical Staff Services Department
CWB Room 204
University Hospital
750 E. Adams Street
Syracuse, NY 13210

All applicants for clinical privileges or medical staff membership, as part of the credentialing and privileging process, must successfully complete a Criminal Background Investigation. Applicants hired by MedBest, or applying for Affiliate or Pediatric Courtesy staff status, must complete the authorization form, and return this to the Medical Staff Services department for processing.

Health Professional Forms

Health Professional Application

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Health Professional Privilege Delineation forms (Must select at least one)

Nurse Practitioner 4NP form (for newly graduated Nurse Practitioners only)

Mandatory Education * (Must complete the HIPAA Education / Confidentiality Agreement, and Infection Control Post-Test)

Bring these Medical Information forms with you to your employee health visit.

Criminal Background Investigations are done on all applicants. Applicants being hired by MedBest should print and complete this Authorization form, and return with your application to the Medical Staff Services department.

Medical Staff 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 complete an application form, at least one delineation form, and complete and submit the Medical Information forms as indicated below.

Application for Medical Staff Appointment

text(Hospital Physicians)

Application for Voluntary / Locum Tenens physicians

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Medical / Clinical Privileges Delineation forms (Must select at least one)

Mandatory Education * (Must complete all modules)

Criminal Background Investigations are done on all applicants. Physician applicants not paid by the Research Foundation or State should print and complete this Authorization form, and return with your application to the Medical Staff Services department. Please note: Faculty being offered a paid position will receive this form from the Office of Faculty Affairs.

Medical Information forms (click here) are viewed only by the medical personnel in the Employee/Student Health.

Medical Information forms and 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
Fax: (315) 464-5471