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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. If your form is not listed, visit the Floyd Medical Center facility page.

Physician Forms


Emergency Medicine

Family Medicine

Hyperbaric Medicine-Wound Care

Internal Medicine

Obstetrics and Gynecology


Pediatric General Dentistry





Surgery Podiatry


Wound Care

Advanced Practice Provider (APP) Forms

Anesthesia - APP

Nurse Practitioner - APP

Physician Assistant - APP

Wound Clinic - APP

Blank Form - APP

Thank you for your commitment to Atrium Health Floyd!