DA Form 5440-15. Delineation of Clinical Privileges-Certified Nurse Midwives

DA Form 5440-15 is the Delineation of Clinical Privileges-Certified Nurse Midwives form used to establish and document the clinical privileges of certified nurse midwives within the Department of the Army. This form outlines the scope of midwifery procedures and responsibilities that certified nurse midwives are authorized to perform.

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

Important fields in this form include practitioner qualifications, requested certified nurse midwife privileges, and specific midwifery procedures authorized. Accurate completion of this form is essential for maintaining proper midwifery standards and patient care.

Application Example: A certified nurse midwife seeks clinical privileges within the Department of the Army. They use DA Form 5440-15 to outline their qualifications, requested midwifery privileges, and the range of midwifery 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 certified nurse midwives.

DA Form 5440-16 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Nurse Practitioner. DA Form 5440-16 is used for nurse practitioners seeking clinical privileges, outlining the scope of medical procedures they are authorized to perform.