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Attending Physician Application and Forms

Initial Medical Staff Application

Physicians applying for privileges have the right to review their application after submission and correct any 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 Medical Staff application in addition to any employment forms; to have a Medical Staff application sent, complete this form and send it to [email protected].

Medical Staff 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.
  • Addendum (practitioners with more than one year of recent clinical inactivity)

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