Mailing Address:  
Fairview Energy Park
Fairview System Credentialing Office
2344 Energy Park Dr Ste 127
St. Paul, MN 55108
General Office
Fax: 612-672-4244

Privilege Forms
Fairview System Credentialing Office

If you're applying for the first time to a Fairview entity, applying to an additional Fairview entity or requesting additional privileges; please follow the steps below:

  1. Print out and complete the appropriate privilege form for your specialty. Note: all threshold criteria and required competency measures as listed on the privilege form must be submitted before your application can be sent to entity for approval.
  2. Click here for a Crosswalk for Requesting Fairview Privileges.
  3. Privilege forms are not required for Fairview Physician Associates (FPA) and Behavioral Healthcare Providers (BHP).

Physicians, Dentists and Podiatrists                                               All Other Health care Practitioners
Acupuncture                                                                                            Acupuncturist
Allergy and Immunology                                                                       Anesthesia Monitoring Tech
Anesthesiology                                                                                       Audiologist
Bariatric Surgery                                                                                     Certified Nurse-Midwife
Breast Ultrasound (Non-Radiologist)                                                Chiropractor
Cardiovascular Disease                                                                       Clinical nurse Specialist
Carotid Stent                                                                                            CRNA - Northland, Lakes
Clinical Bone Densitometry                                                                  CRNA - Ridges, UMMC, MGASC, Southdale
Colon and Rectal Surgery                                                                      Dental Assistant
Colonoscopy and Snare Polypectomy                                                Genetics Counselor
Computer Enhanced Surgical Device                                                 Licensed Practical Nurse
Critical Care                                                                                             Medication Therapy Management
Dentistry                                                                                                    Mental Health Service Provider - Bachelor's Level
Dermatology                                                                                             Mental Health Service Provider - Master's Level
Emergency Medicine                                                                              Monitoring Tech
Endocrinology                                                                                          Neurophys Intraoperative Monitor
Extracorporeal Membrane Oxygenation (ECMO)                              Non-Physician Surgical First Assistant
Family Medicine   
                                                                                                                    Nurse Practitioner
Gamma Knife                                                                                           Occupational Therapy - UMMC Memory Clinic
Gastroenterology                                                                                     Optometrist
Hematology -  Medical Oncology                                                           Orthopaedic Assistant - Non-Licensed
Hospice and Palliative Medicine                                                           Orthoptist
House                                                                                                         Perfusionist
House - Psychiatry                                                                                    Physician Asst & Orthopaedic Physician Asst.
House -  Surgery                                                                                       Psychologist
Infectious Disease                                                                                   Radiology Practitioner Assistant
Internal Medicine                                                                                       Registered Nurse
                                                                                                                     Retail Clinical Services Pharmacist
Moderate and Deep Sedation - Initial                                                   Social Worker - UMMC Memory Clinic
  Note: Must also complete Moderate                                                   Specialty Therapy Management Pharmacist
                                                                                                                     Speech Pathologist
  and Deep Sedation Learning Packet                                                 Surgical Tech & Ophthalmic Surg Tech
Moderate and Deep Sedation - REAPP
Neurological Surgery
Newborn Transport
OB/GYN & Subspecialties
Occupational Medicine
Oral & Maxillofacial Surgery
Orthopaedic Surgery
Pain Medicine
Pediatric Cardiovascular Disease
Pediatric Emergency Medicine
Pediatric Surgery
Physical Medicine and Rehabilitation
Plastic Surgery
Pulmonary Diseases
Sleep Medicine
Sports Medicine
       -UMMC Cesarean Section
Telemedicine -  Endocrinology
Telemedicine - Neurology
Therapeutic Radiology - Radiation Oncology
Thoracic - Cardiovascular Surgery
Transplant Medicine
Transplant Surgery
Urgent Care/Retail Clinic



 Visit Other Fairview Sites 
(c) 2012 Fairview Health Services. All rights reserved.