New Clinical Privilege/Practice Site Submission Form For Existing Providers

Requests to add NEW CLINICAL PRIVILEGE/PRACTICE SITES  for existing clinical providers* are to be completed and submitted only by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates. 


  1. If a new clinical hire, requests to add a NEW PROVIDER should be submitted through the New Clinical Provider Submission Form.
  2. If you need to add more than 10 new privilege/practice sites, STOP .. please do not use this process; rather, call your SIP Insurance Services team directly at the following phone # for assistance: 352-273-7006, or 844- MY FL SIP.

The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes only and does not meet participants’ independent credentialing or other required hiring background, screening, and/or on boarding processes.

* Providers (employees or volunteers) who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.

Please complete the below and allow up to seven business days for processing by your SIP Insurance Services Office (ISO).  This form allows for the addition of up to three sites per provider.  If additional sites are needed, a new form will need to be completed and submitted.  Once processed by ISO, the new privilege/practice site(s) will appear in your portal detail.


(e.g., COM Radiology, CON, Student Health Services, etc.)


Each Practice Site will need to be added individually.


Geographic location of practice is a factor in underwriting the exposure. For example, an OBGYN exposure in South Florida is higher than the same exposure in North Florida.
The date the provider is to begin delivering healthcare services at this facility.
Click or drag files to this area to upload. You can upload up to 10 files.