Cherokee Medical Center Forms

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.

• Print and complete the Delineation of Privileges (DOP) that reflects your specialty/current practice.
• Return all pages of the form(s) in PDF format to the coordinator assigned to you:
  • Latasha Bolton - Latasha.Bolton@AtriumHealth.org
  • Shawanta Whitehead - Shawanta.Whitehead@AtriumHealth.org
  • Sheri Carter - Sheri.Carter@AtriumHealth.org

If you have additional questions, email Shauna Guy Noel, Supervisor, Medical Staff Services.

Click on the link below to print and complete the Delineation of Privileges form. If you form is not listed, visit the Floyd Medical Center facility page.

Physician Forms

Anesthesiology (can be used for AH Floyd, AH Polk and AH Cherokee)

Emergency Medicine (can be used for AH Floyd, AH Polk and AH Cherokee)

Family Medicine (can be used for AH Floyd, AH Polk and AH Cherokee) 

Internal Medicine (can be used for AH Floyd, AH Polk and AH Cherokee)

Obstetrics and Gynecology (can be used for AH Floyd, AH Polk and AH Cherokee)

Pathology

Pediatric General Dentistry

Pediatrics (can be used for AH Floyd, AH Polk and AH Cherokee)

Psychiatry

Radiology (can be used for AH Floyd, AH Polk and AH Cherokee)

Surgery(can be used for AH Floyd, AH Polk and AH Cherokee)

Advanced Practice Provider (APP) Forms

Anesthesia - APP  (can be used for AH Floyd, AH Polk and AH Cherokee)

Nurse Practitioner - APP  (can be used for AH Floyd, AH Polk and AH Cherokee)

Physician Assistant - APP(can be used for AH Floyd, AH Polk and AH Cherokee)

Blank Form - APP

Thank you for your commitment to Atrium Health Floyd!