DA Form 5440. Delineation of Clinical Privileges-Anesthesia

DA Form 5440 is the Delineation of Clinical Privileges-Anesthesia form used to establish and document the clinical privileges of medical practitioners in the field of anesthesia. This form outlines the scope of procedures and responsibilities that practitioners are authorized to perform.

The form consists of sections where the practitioner's information is provided, including their qualifications and requested privileges. It may also include sections for listing specific procedures and detailing any restrictions or limitations.

Important fields in this form include practitioner qualifications, requested privileges, and specific procedures authorized. Accurate completion of this form is essential for maintaining proper medical standards and patient safety.

Application Example: A medical doctor seeks clinical privileges in the field of anesthesia. They use DA Form 5440 to outline their qualifications, requested privileges, and the range of anesthesia procedures they are qualified to perform.

No additional documents are typically required to complete this form, as it captures all necessary information related to delineating clinical privileges for anesthesia practitioners.

DA Form 5440-1 is a related form that serves a similar purpose but is specific to dentistry. DA Form 5440-1 is used for the Delineation of Clinical Privileges-Dentistry, outlining the clinical privileges and authorized dental procedures for practitioners in the dental field.