Privilege Change Request Form
To request an update to your supervising physician, practicing specialty and/or if you are requesting 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.
Specialty Request Note: If you are changing your specialty please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.
Supervising Physician Request Note: If you are changing your supervising physician please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.
Updated Delineation Privileges Request Note: This change will only apply to those facilities where you currently hold privileges.
Additional Facility Request Note: If you are requesting privileges at any of the Atrium Health facilities where you don't currently hold privileges please contact the Medical Staff Office to complete a New Application via email.To request an update to your current delineation of privilege(s) form to include new privileges at one or more of the Carolinas HealthCare system facilities please complete and submit this form.To request a change in classification or to request clinical privileges at any or all of the Atrium Health facilities please complete and submit this form. Please note that you must have current membership at of the Atrium Health facilities listed.
Specialty Request Note: If you are changing your specialty please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.
Supervising Physician Request Note: If you are changing your supervising physician please DO NOT remove your current supervising physician until you have received approval from the Medical Staff Office. This requires an update to your North Carolina License.
Updated Delineation Privileges Request Note: This change will only apply to those facilities where you currently hold privileges.
Additional Facility Request Note: If you are requesting privileges at any of the Atrium Health facilities where you don't currently hold privileges please contact the Medical Staff Office to complete a New Application via email.To request an update to your current delineation of privilege(s) form to include new privileges at one or more of the Carolinas HealthCare system facilities please complete and submit this form.To request a change in classification or to request clinical privileges at any or all of the Atrium Health facilities please complete and submit this form. Please note that you must have current membership at of the Atrium Health facilities listed.