DA Form 5440-12. Delineation of Clinical Privileges-Diagnostic Radiology

DA Form 5440-12 is the Delineation of Clinical Privileges-Diagnostic Radiology form used to establish and document the clinical privileges of diagnostic radiology practitioners within the Department of the Army. This form outlines the scope of diagnostic radiology procedures and responsibilities that practitioners are authorized to perform.

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

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

Application Example: A diagnostic radiologist seeks clinical privileges within the Department of the Army. They use DA Form 5440-12 to outline their qualifications, requested diagnostic radiology privileges, and the range of 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 diagnostic radiology practitioners.

DA Form 5440-13 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-General Surgery. DA Form 5440-13 is used for general surgeons seeking clinical privileges, outlining the scope of surgical procedures they are authorized to perform.