DA Form 5440-43. Delineation of Clinical Privileges - Ophthalmology

DA Form 5440-43 is utilized for the delineation of clinical privileges specifically related to the field of Ophthalmology. This form serves as a comprehensive record for medical practitioners to request and establish the scope of clinical privileges within the realm of ophthalmic care.

The form consists of sections where the medical professional provides personal information, qualifications, and experience in the field of ophthalmology. It requires detailing the specific clinical privileges being sought, such as diagnostic procedures, therapeutic interventions, and surgical capabilities. The form also includes spaces to list any relevant certifications and training that support the requested privileges.

Important fields in this form include the practitioner's name, license number, and signature, along with the specific privileges being sought. Accurate completion of this form is crucial, as it directly impacts the practitioner's scope of practice within the specialized field of ophthalmology.

Application Example: A board-certified ophthalmologist seeking privileges at a military medical facility would use DA Form 5440-43 to request clinical privileges. The practitioner would complete the form accurately, including details of their qualifications, experience, and requested privileges. This submission enables the medical facility to assess and determine the appropriate clinical privileges for the practitioner, ensuring safe and quality patient care in ophthalmology.

No additional documents are explicitly mentioned as required for filling this form.

Related Form: DA Form 5440-44, 5440-45, 5440-46, 5440-47 are related forms designed for the delineation of clinical privileges in different medical specialties.