Carolinas Gastro Centers Forms

Please follow the steps below to complete Phase I - Clinical Privileges Update of the reappointment process for Atrium Health Endoscopy Center Ballantyne and Atrium Health Endoscopy Center Kenilworth privileges.

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 the form(s) to the coordinator assigned to you.
• Allison Eury - Allison.Eury@AtriumHealth.org
• Demetrice Ford - Demetrice.Ford@AtriumHealth.org

If you have additional questions, you may email Staci Hightower, Supervisor.

Gastroenterology Delineation of Privileges form - Physician form

Certified Registered Nurse Anesthetist Delineation of Privileges form - APP form

Thank you for your commitment to Atrium Health!