Granting approval for an individual to perform a specific procedure or scope of practice based on documented competence in the specialty in which privileges are requested.

Please follow these instructions:

  1. Scroll down to locate the appropriate privilege form for your specialty
  2. Print and complete the privileges PDF form by putting a checkmark or "X" where indicated for the desired core privileges and special request privileges
  3. Check only the privileges for which you wish to apply
  4. Provide complete contact information for references
  5. Sign and date where indicated
  6. Fax completed form to 410-554-2505 or mail to:

    Medical Staff Services
    201 East University Parkway,
    33rd Street Professional Building, Room 257
    Baltimore, Maryland 21218

Delineation of privileges