Medical Staff Services

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Clinical Privileges Application Documents

Follow the steps listed below. Once complete, return all documents directly to Medical Staff Services by email, by fax to (601) 984-4119, or by U.S. mail to 2500 N. State St., Jackson, MS 39216. Contact us at (601) 984-4124 if there are any questions about the required documents.

Step 1 - Application forms

Print and complete ALL documents in this section (Click on the form name to access the document). Note that applications will not be accepted and/or processed without department approval. 

Step 2 - Information related to application forms

It is not necessary to print the documents below. They are provided for your review as you complete your application documents.

Step 3 - Clinical privilege documents

Print and complete only applicable documents from this section. (Click on the form name to access the document.)