DA Form 5440-56. Delineation of Clinical Privileges - Blood Services

DA Form 5440-56 is intended for the delineation of clinical privileges within the field of Blood Services. This form serves as a formal request for medical practitioners to establish their qualifications and requested privileges related to blood donation, collection, and transfusion.

The form includes sections where the practitioner provides personal and professional details, including medical licenses, certifications, and qualifications. It requires outlining the requested clinical privileges, covering areas such as blood donation, component processing, and blood transfusion services.

Important fields in this form include the practitioner's identification information, requested clinical privileges, and supporting evidence of their expertise in blood services. Accurate completion of this form is vital to ensure that the practitioner is granted privileges aligned with their proficiency in blood donation and transfusion practices.

Application Example: A certified blood bank specialist joining a military medical facility would utilize DA Form 5440-56 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in blood services is evaluated, enabling the medical facility to grant appropriate privileges for managing blood donation and transfusion processes.

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

Related Form: DA Form 5440-52, 5440-53, 5440-54, and 5440-55 are related forms intended for different medical specialties, each tailored for specific clinical privileges.