DA Form 5440-34. Delineation of Clinical Privileges - Behavioral Health Practitioner

DA Form 5440-34 is the Delineation of Clinical Privileges - Behavioral Health Practitioner form used to establish and document the clinical privileges of behavioral health practitioners within the Department of the Army. This form outlines the scope of behavioral health procedures and responsibilities that practitioners are authorized to perform.

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

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

Application Example: A behavioral health practitioner seeks clinical privileges within the Department of the Army. They use DA Form 5440-34 to outline their qualifications, requested behavioral health privileges, and the range of 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 behavioral health practitioners.

DA Form 5440-30 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges - Nephrology. DA Form 5440-30 is used for nephrology practitioners seeking clinical privileges, outlining the scope of procedures they are authorized to perform.