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

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

**Application for Medical Staff Appointment text (Hospital Physicians)
- Documentation required
- Mandatory Education
**Application for Voluntary Clinical Appointment / Locum Tenens text(Community Physicians)
- Documentation required
- Mandatory Education
Application for Health Professional Appointment text
- Documentation required
- Mandatory Education

**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.