DA Form 5441-58. Evaluation of Clinical Privileges - Substance Abuse Rehabilitation
DA Form 5441-58 serves the purpose of evaluating clinical privileges for practitioners specializing in Substance Abuse Rehabilitation. This form is crucial in assessing and establishing the qualifications and requested privileges for medical professionals engaged in substance abuse treatment and rehabilitation.
The form comprises sections where the practitioner provides personal and professional details, including licenses, certifications, and qualifications specific to substance abuse rehabilitation practice. It requires outlining the requested clinical privileges, covering areas such as substance use assessments, therapy interventions, and addiction management.
Important fields in this form include the practitioner's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in substance abuse rehabilitation. Accurate completion of this form is vital to ensure that the practitioner is granted privileges aligned with their proficiency in diagnosing and treating substance use disorders.
Application Example: A licensed counselor specializing in substance abuse rehabilitation joining a military medical facility would use DA Form 5441-58 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in substance use assessments and addiction therapy is evaluated, enabling the medical facility to grant appropriate privileges.
No additional documents are explicitly mentioned as required for filling this form.
Related Form: DA Form 5441-55, 5441-56, 5441-57, and 5441-6 are related forms intended for different clinical privilege evaluation processes.