Mask and Visitor Policies: Following CDC and state of NC guidance, masks are still required in all Atrium Health facilities. View our current visitor policy

/-/media/chs/files/for-employees/medical-staff-services/clinical-privileges-update-forms/2020-reappt-dops/reappt-dop-2020---cmc-c-brevital-for-cardioversion.pdfPlease follow the steps below to complete Phase I - Clinical Privileges Update of the reappointment process. 

1) PRINT and COMPLETE - the Delineation of Privileges (DOP) that reflects your specialty/current practice

2) NOTE - if you wish to keep a privilege that is attached to maintenance criteria, you must provide proof of that maintenance criteria in order to maintain the privilege

3) NOTE - if you are requesting a privilege you currently do not have, you must meet the initial criteria for that privilege.

4) RETURN the form(s) to the coordinator assigned to you

 If you have additional questions you may contact Katrina Barkley, Reappointment Team lead here.

(Ambulatory Surgery Center links are listed at the bottom of this page)

Physician Forms:  (see bottom of page for APP forms)

Addiction Medicine

Allergy and Immunology


Anesthesia for Cardioversion (for Cardiologists)

Anesthesia Critical Care Medicine




Emergency Medicine


Family Medicine

Family Medicine - Obstetrics

Gastroenterology - Atrium Health facilities

Gastroenterology - Carolina Gastro Centers


Hospice and Palliative

Hospitalist (Internal Medicine and Family Medicine)

Hyperbaric Medicine and Wound Care Medicine

Infectious Disease

Internal Medicine - General

Medical Genetics

Medical Toxicology




Obstetrics & Gynecology


Optometry - Independent Practitioner

Oral & Maxillofacial Surgery

Orthopaedic Surgery




Pediatrics - Cardiology

Pediatric General Surgery

Physical Medicine and Rehabilitation

Peripheral Endovascular Privileges

Plastic Surgery


Pulmonary Disease

Radiation Oncology


Radiology - Union West providers only


Sedation - Moderate - you must also complete the Sedation test(s) HERE to maintain these privileges

Sleep Medicine

General Surgery

Thoracic & Cardiovascular Surgery


Vascular Ultrasound - NE providers only - Non-radiology


*Please make sure to complete additional forms for Sedation or Peripheral Endovascular privileges,if applicable.


Advanced Practice Provider (APP) Forms:

Anesthesiology - APP

Certified Nurse Midwife - APP

Certified Registered Nurse Anesthetist (CRNA)

Dentistry - Independent Practitioner- APP

Emergency Medicine - APP

Family Medicine - APP

General Surgery

Hospice and Palliative - APP

Internal Medicine - APP

Neurological Surgery - APP

Neurology - APP

Obstetrics & Gynecology - APP

Oral & Maxillofacial - APP

Orthopaedic Surgery - APP

Otolaryngology - APP

Pediatrics - APP

Physical Medicine and Rehabilitation - APP

Plastic Surgery - APP

Podiatry - Independent Practitioner - APP

Psychiatry - APP

Psychology - APP

Radiology - APP

Registered Nurse First Assist - APP

Surgical Critical Care - APP

Thoracic Surgery - APP

Urology - APP

Wound Care Medicine - STA providers only - APP


Cleveland Ambulatory Services (CAS) - Physician and Allied Health

Center for Orthopaedic Surgery (COS) - Physician and Allied Health

Union West Surgery Center - Physician and Allied Health

Thank you for your commitment to Atrium Health!