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Credentialing and privileging form for nurses

Privilege form for nurses 2026

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The document outlines the delineation of privileges for Physician Assistants and Advanced Registered Nurse Practitioners, detailing the procedures they are authorized to perform, including general procedures, surgery assistance, cardiology, gynecology, and orthopedics. It includes sections for requesting privileges, documentation requirements, and signatures from both the applicant and supervising physician to confirm competency and supervision.

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Click ‘Get Form’ to open the privilege form for nurses in the editor.
Begin by entering your name and the date at the top of the form. This personal information is essential for identification.
In the 'Requested' section, place an 'X' in the boxes next to the privileges you wish to request. Ensure you review each category carefully, including General Procedures, General Surgery Procedures, Cardiology Procedures, Gynecology Procedures, and Orthopedics Procedures.
If you are requesting privileges not listed on the form, please specify them under 'Other Procedures' and attach any necessary documentation of training or experience.
Sign and date the application at the bottom of the form to certify your qualifications. Additionally, ensure that your supervising physician acknowledges your competencies by signing where indicated.

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