DA Form 5440-19. Delineation of Clinical Privileges-Dietetics

DA Form 5440-19 is the Delineation of Clinical Privileges-Dietetics form used to establish and document the clinical privileges of dietitians within the Department of the Army. This form outlines the scope of dietetic procedures and responsibilities that dietitians are authorized to perform.

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

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

Application Example: A dietitian seeks clinical privileges within the Department of the Army. They use DA Form 5440-19 to outline their qualifications, requested dietetics privileges, and the range of dietetic 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 dietitians.

DA Form 5440-1 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Dentistry. DA Form 5440-1 is used for dental practitioners seeking clinical privileges, outlining the scope of dental procedures they are authorized to perform.