DA Form 4691. Initial Application for Clinical Privileges and Staff Appointment
Form DA 4691 is used as an Initial Application for Clinical Privileges and Staff Appointment in medical facilities within the Army. This form serves as an application tool for healthcare professionals seeking clinical privileges and staff appointments at the facility.
The form consists of sections where the applicant's personal and professional information, including qualifications, education, and experience, are recorded. It includes details of the requested clinical privileges and the medical specialty or department for which the appointment is sought. Additionally, the form may include sections for obtaining references and endorsements from other medical professionals.
Important fields in this form include accurate and comprehensive documentation of the applicant's qualifications and requested clinical privileges. Accurate completion of this form is crucial to ensure that healthcare professionals meet the necessary requirements and qualifications for the desired clinical privileges and staff appointments.
Application Example: A medical doctor wishes to join a military hospital's medical staff and apply for specific clinical privileges. The doctor completes Form DA 4691, providing detailed information about their medical qualifications, education, and previous experience. The completed form is then submitted to the medical facility's credentials committee for review and approval. By doing so, the medical facility ensures that only qualified and competent healthcare professionals are granted clinical privileges and staff appointments.
Individuals filling out this form should consider any additional supporting documents, such as professional certifications or letters of recommendation, that may be required to support their application for clinical privileges and staff appointment.
Related Forms: There may not be direct alternatives to Form DA 4691, as it serves as a specialized application form for clinical privileges and staff appointments in Army medical facilities. However, there might be other forms related to medical staff credentialing or privileges application used in similar medical settings.