DA Form 5440-49. Delineation of Clinical Privileges - Plastic Surgery

DA Form 5440-49 is designed for the delineation of clinical privileges within the field of Plastic Surgery. This form facilitates the documentation and evaluation of a medical practitioner's qualifications and requested privileges related to cosmetic and reconstructive surgical procedures.

The form comprises sections where the practitioner provides their personal and professional details, including medical licenses, certifications, and qualifications. It also requires outlining the requested clinical privileges, covering a range of plastic surgical interventions.

Important fields in this form include the practitioner's identifying information, requested clinical privileges, and supporting documentation showcasing their expertise in plastic surgery. Accurate completion of this form is crucial to ensure that the practitioner is granted clinical privileges aligned with their skill set and experience.

Application Example: A board-certified plastic surgeon joining a military medical facility would utilize DA Form 5440-49 to request clinical privileges. By accurately completing the form and submitting necessary documentation, the practitioner's proficiency in cosmetic and reconstructive surgery is assessed, enabling the medical facility to grant appropriate privileges.

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

Related Form: DA Form 5440-48, 5440-5, 5440-50, and 5440-51 are related forms intended for different medical specialties, each tailored for specific clinical privileges.