**PLEASE READ PRIOR TO THE COMPLETION OF THIS FORM

Use this form to request privileges at Piedmont Atlanta, Fayette, Henry, Mountainside, Newnan, Newton, Rockdale and Walton Hospitals. 

To request physician privileges at Piedmont Athens Regional, CLICK HERE

For privileges at Athens and one or more of the other hospitals, please complete both forms. Applicable fees are payable by credit card as indicated on both forms.