DA Form 5440-3. Delineation of Clinical Privileges-Internal Medicine

DA Form 5440-3 is the Delineation of Clinical Privileges-Internal Medicine form used to establish and document the clinical privileges of internal medicine physicians within the Department of the Army. This form outlines the scope of medical procedures and responsibilities that internal medicine physicians are authorized to perform.

The form consists of sections where the internal medicine physician'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 internal medicine privileges, and specific medical procedures authorized. Accurate completion of this form is crucial for maintaining proper medical standards and patient care.

Application Example: An internal medicine physician seeks clinical privileges within the Department of the Army. They use DA Form 5440-3 to outline their qualifications, requested internal medicine 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 internal medicine physicians.

DA Form 5440-24 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Aerospace Medicine. DA Form 5440-24 is used for aerospace medicine physicians seeking clinical privileges, outlining the scope of medical procedures they are authorized to perform.