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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.

New applicants MUST complete the initial application and privilege forms; to receive an application, complete this form and email it to [email protected].



Required Education (Complete all of the below):

For your convenience (if you have not already submitted a current certificate):

If requesting special privileges, complete the appropriate education or form (s):

* Signed documents may be uploaded to your application using the MD-App Application or faxed to 315-464-8524.

Required Health Forms:

Please download and complete: 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