DA Form 5440-1. Delineation of Clinical Privileges-Dentistry

DA Form 5440-1 is the Delineation of Clinical Privileges-Dentistry form used to establish and document the clinical privileges of dental practitioners. This form outlines the scope of dental procedures and responsibilities that practitioners are authorized to perform within the Department of the Army.

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

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

Application Example: A dental professional seeks clinical privileges within the Department of the Army. They use DA Form 5440-1 to outline their qualifications, requested dental privileges, and the range of dental 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 dental practitioners.

DA Form 5440 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Anesthesia. DA Form 5440 is used for medical practitioners seeking clinical privileges in anesthesia, outlining the scope of anesthesia procedures they are authorized to perform.