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