DA Form 5440-36. Delineation of Clinical Privileges - Audiology

DA Form 5440-36 is the Delineation of Clinical Privileges - Audiology form used to establish and document the clinical privileges of audiologists within the Department of the Army. This form outlines the scope of audiology assessment and treatment procedures that audiologists are authorized to perform.

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

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

Application Example: An audiologist seeks clinical privileges within the Department of the Army. They use DA Form 5440-36 to outline their qualifications, requested audiology privileges, and the range of assessment and treatment 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 audiologists.

DA Form 5440-35 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges - Psychological Associate. DA Form 5440-35 is used for psychological associates seeking clinical privileges, outlining the scope of procedures they are authorized to perform.