DA Form 5440-41. Delineation of Clinical Privileges - Physical Medicine and Rehabilitation

DA Form 5440-41 is the Delineation of Clinical Privileges - Physical Medicine and Rehabilitation form used to establish and document the clinical privileges of practitioners in the field of physical medicine and rehabilitation within the Department of the Army. This form outlines the scope of assessment and treatment procedures that practitioners are authorized to perform in the realm of physical medicine and rehabilitation.

The form consists of sections where the practitioner's information is provided, including qualifications and requested privileges related to physical medicine and rehabilitation. It may also include sections for listing specific procedures and detailing any restrictions or limitations within this medical specialty.

Important fields in this form include practitioner qualifications, requested physical medicine and rehabilitation privileges, and specific assessment and treatment procedures authorized. Accurate completion of this form is vital to ensuring proper standards of physical medicine and rehabilitation care and patient safety.

Application Example: A physical medicine and rehabilitation practitioner seeks clinical privileges within the Department of the Army. They use DA Form 5440-41 to outline their qualifications, requested privileges, and the range of assessment and treatment procedures they are qualified to perform in the field of physical medicine and rehabilitation.

No additional documents are typically required to complete this form, as it captures all necessary information related to delineating clinical privileges for physical medicine and rehabilitation practitioners.