DA Form 5440-40. Delineation of Clinical Privileges - Therapeutic Radiology

DA Form 5440-40 is the Delineation of Clinical Privileges - Therapeutic Radiology form used to establish and document the clinical privileges of therapeutic radiologists within the Department of the Army. This form outlines the scope of therapeutic radiology assessment and treatment procedures that practitioners are authorized to perform.

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

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

Application Example: A therapeutic radiologist seeks clinical privileges within the Department of the Army. They use DA Form 5440-40 to outline their qualifications, requested therapeutic radiology 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 therapeutic radiologists.