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:
- 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.
- Click here for a Crosswalk for Requesting Fairview Privileges.
- 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 Audiologist
Anesthesiology Cardiovascular Monitoring Technician
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, 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
-UMMC Cesarean Section Nurse Practitioner
Gamma Knife Occupational Therapy - UMMC Memory Clinic
Gastroenterology Optometrist
Genetics Oral Surgeon Assistant
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 Speech Pathologist
and Deep Sedation Learning Packet Surgical Tech & Ophthalmic Surg Tech
Moderate and Deep Sedation - REAPP
Nephrology
Neurological Surgery
Neurology
Newborn Transport
OB/GYN & Subspecialties
Occupational Medicine
Ophthalmology
Oral & Maxillofacial Surgery
Orthopaedic Surgery
Otolaryngology
Pain Medicine
Pathology
Pediatrics
Pediatric Cardiovascular Disease
Pediatric Emergency Medicine
Pediatric Surgery
Physical Medicine and Rehabilitation
Plastic Surgery
Podiatry
Psychiatry
Pulmonary Diseases
Radiology
Rheumatology
Sleep Medicine
Sports Medicine
Surgery
-UMMC Cesarean Section
Telemedicine - Endocrinology
Telemedicine - Neurology
Telemedicine - Sleep Medicine
Therapeutic Radiology - Radiation Oncology
Thoracic - Cardiovascular Surgery
Transplant Medicine
Transplant Surgery
Urgent Care/Retail Clinic
Urology
