Please follow the steps below to complete Phase I 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 Staci Hightower, Reappointment Supervisor here.

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

Physician Forms:

Addiction Medicine

Allergy and Immunology



Emergency Medicine


Family Medicine

Family Medicine - Obstetrics



Hospice and Palliative


Hyperbaric Medicine and Wound Care Medicine

Infectious Disease

Internal Medicine - General

Medical Genetics

Medical Toxicology




Pediatrics - Cardiology

Physical Medicine and Rehabilitation

Peripheral Endovascular (CMC, PVL, UNV)

Peripheral Endovascular - NE

Peripheral Endovascular - UNN


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

Vascular Ultrasound - NE providers only - Non-radiology

*Please make sure to complete additional forms for Sedation or Peripheral Endovascular privileges,depending on your specialty.


Advanced Clinical Practitioner (ACP) Forms:

Emergency Medicine - ACP

Family Medicine - ACP

Hospice and Palliative - ACP

Internal Medicine - ACP

Neurology - ACP

Pediatrics - ACP

Physical Medicine and Rehabilitation - ACP

Psychiatry - ACP

Psychology - ACP

Radiology - ACP

Wound Care Medicine - STA providers only - ACP


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!