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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, email Shauna Guy Noel, Supervisor, Medical Staff Services.

Click on the link below to print and complete the Delineation of Privileges form.

Physician Forms


Dermatoalogic Services

Emergency Medicine

Family Medicine

Hyperbaric Medicine

Internal Medicine


Pediatric General Dentistry



Radiation Oncology


Advanced Practice Provider (APP) Forms

Anesthesia - APP

Certified Nurse Midwife - APP

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

Nurse Practitioner Breast Center - APP

Pathology - APP

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

Radiation Oncology - APP

Wound Clinic - APP

Blank Form - APP

Thank you for your commitment to Atrium Health Floyd!