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Please follow the steps below to complete Phase I - Clinical Privileges Update of the reappointment process.

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.

If you are requesting a privilege you currently do not have, you must meet the initial criteria for that privilege.

If you have additional questions you may email Katrina Barkley, Reappointment Supervisor.

Ambulatory Surgery Center, Endoscopy Center and Scotland Health Care forms are at the bottom of this page.

Physician 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 - PEV

Plastic Surgery


Pulmonary Disease

Radiation Oncology


Radiology - Union West providers only


Sedation - Moderate

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 - Cabarrus

Emergency Medicine - APP

Family Medicine - APP

General Surgery - Surgical Critical Care - APP

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

Sedation - Moderate

Thoracic Surgery - APP

Urology - APP

Wound Care Medicine - STA providers only - APP

Ambulatory Surgery Center, Endoscopy Center and Scotland Forms

Scotland Health Care System - APP and Physician Forms

Atrium Health Surgery Center Shelby - APP and Physician Forms

Center for Orthopaedic Surgery (COS) - APP and Physician Forms

Atrium Health Surgery Center Indian Trail - APP and Physician Forms

Carolinas Gastro Centers - Kenilworth and Ballantyne location - APP And Physician Forms

Thank you for your commitment to Atrium Health!