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To request an update to your current delineation of privilege(s) form to include new privileges at one or more of the Atrium Health facilities please complete and submit this form. Please note that you must have current membership at one of the Atrium Health facilities listed.

You can begin performing newly requested clinical procedures once an approval/clearance notification is received from Medical Staff Services.

Requests are processed in the order they are received. A Medical Staff Services Teammate will be in contact with you after your file has been assigned. If you have any questions or have not heard from us, please email us at

Atrium Health Privilege Location (s): Please select all facilities where the new privilege (s) will be requested.

Case Log/Documentation, if applicable

We will only accept PDF, DOC, DOCX and TXT files under 2MB in size.

If your case log is over 2MB in size, please email the documentation to