DA Form 5440-21. Delineation of Clinical Privileges-Physical Therapy

DA Form 5440-21 is the Delineation of Clinical Privileges-Physical Therapy form used to establish and document the clinical privileges of physical therapists within the Department of the Army. This form outlines the scope of physical therapy procedures and responsibilities that therapists are authorized to perform.

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

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

Application Example: A physical therapist seeks clinical privileges within the Department of the Army. They use DA Form 5440-21 to outline their qualifications, requested physical therapy privileges, and the range of therapy 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 physical therapists.

DA Form 5440-20 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Occupational Therapy. DA Form 5440-20 is used for occupational therapists seeking clinical privileges, outlining the scope of occupational therapy procedures they are authorized to perform.