DA Form 4691-1. Application for Renewal of Clinical Privileges and Staff Appointment

Form DA 4691-1 is used as an Application for Renewal of Clinical Privileges and Staff Appointment in medical facilities within the Army. This form serves as an application tool for healthcare professionals seeking the renewal of their clinical privileges and staff appointment at the facility.

The form consists of sections where the applicant's personal and professional information, including any updates to qualifications or experience, are recorded. It includes details of the previously granted clinical privileges and the medical specialty or department in which the appointment is held. Additionally, the form may include sections for obtaining updated references and endorsements from other medical professionals.

Important fields in this form include accurate and up-to-date documentation of the applicant's qualifications and the requested renewal of clinical privileges. Accurate completion of this form is crucial to ensure that healthcare professionals continue to meet the necessary requirements and qualifications for the renewal of their clinical privileges and staff appointment.

Application Example: A medical doctor who currently holds clinical privileges and staff appointment at a military hospital seeks to renew their appointment. The doctor completes Form DA 4691-1, providing updated information about their medical qualifications and any recent professional developments. 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 continue to hold clinical privileges and staff appointments.

Individuals filling out this form should consider any additional supporting documents, such as continuing education certificates or performance evaluations, that may be required to support their application for renewal of clinical privileges and staff appointment.

Related Forms: There may not be direct alternatives to Form DA 4691-1, as it serves as a specialized renewal 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 renewal used in similar medical settings.