DA Form 5440-22. Delineation of Clinical Privileges

DA Form 5440-22 is the Delineation of Clinical Privileges form used to establish and document the clinical privileges of healthcare practitioners within the Department of the Army for whom specific specialty forms are not available. This form outlines the scope of medical procedures and responsibilities that practitioners are authorized to perform.

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

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

Application Example: A healthcare practitioner with a unique specialty seeks clinical privileges within the Department of the Army for which a specific form is not available. They use DA Form 5440-22 to outline their qualifications, requested privileges, and the range of medical 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 practitioners without specialty-specific forms.

DA Form 5440-1 to 5440-21 are related forms that serve specific purposes for different healthcare specialties. DA Form 5440-22 is a more general form that covers healthcare practitioners for whom specialty-specific forms are not available.