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).

New applicants MUST complete the initial application and privilege forms; if you have not received an invitation, please e-mail medstaff@upstate.edu with your name, specialty, and email address.

Application

• 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.
  • Summary of Rights
  • Article 23-A, Section 753
• Addendum (practitioners with more than one year of recent clinical inactivity)

Required Education (Complete all of the below):

• Title IX, Clery Act & Sexual Harassment Prevention Training
• Credentialed Provider Mandatory Education
• Credentialed Provider Orientation
• Electronic Death Registry System (EDRS)
• Fire Safety in the OR
• Keep Upstate Safe
• Positioning Patients in Surgery

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

• Infection Control

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

• 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
• Surgical Laser Safety
  Surgical Laser Safety training requires login; please contact your coordinator for a Username and Password. (If you score less than 80%, you will need to call (315) 464-5733 to have the test reset before you can retake it.)
• Davinci Surgery

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