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To request an update to your supervising physician, practicing specialty and/or if you are requesting an update to your current delineation of privilege(s) form to include new privileges at one or more of the Atrium Health facilities please complete and submit this form.


Specialty Request Note: If you are changing your specialty please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.


Supervising Physician Request Note: If you are changing your supervising physician please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.


Updated Delineation Privileges Request Note: This change will only apply to those facilities where you currently hold privileges. To request an update to your current privileges at one or more of the Atrium Health facilities please complete and submit this form.  A Medical Staff Office teammate will contact you soon.


Additional Facility Request Note: If you are requesting privileges at any of the Atrium Health facilities where you don't currently hold privileges please complete and submit this form.  A Medical Staff Office teammate will contact you soon.  You will be provided a link to access your online application for any additional facilities you wish to add. 
Current Atrium Health Privileges Location(s): List all facilities where the change(s) will take place.
Additional Facility Request-Indicate where you are requesting privileges.
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