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To request a change in classification or to request clinical privileges at any or all of the Atrium Health facilities please complete and submit this form. Please note that you must have current membership at one of the Atrium Health facilities listed.

Requests are processed in the order they are received. A Medical Staff Services Teammate will be in contact with you after your file has been assigned. If you have any questions or have not heard from us, please email us at

Classification Guide:

  • Active - Full onsite admitting privileges. This includes telemedicine privileges.
  • Affiliate - Membership only. No hospital or hospital-licensed clinic privileges. No admitting or consults.
  • Courtesy - Full onsite admitting privileges with less than 30 encounters per year. This includes telemedicine privileges.
  • Honorary - Have retired from active practice or have an outstanding professional reputation.
  • Leave of Absence - No hospital or hospital-licensed privileges during LOA. LOA are limited to greater than 30 days and less than 366 days.
  • Telemedicine - Virtual consults only. No onsite privileges and cannot admit.

Please Select Desired Clinical Privilege Location and/or Classification Change. Changes to the Affiliate and or Telemedicine Classification may require an update to your delineation of privileges form.