DA Form 5440-58. Delineation of Clinical Privileges - Substance Abuse Rehabilitation

DA Form 5440-58 serves as a crucial tool for delineating clinical privileges related to Substance Abuse Rehabilitation. This form is used to assess and establish the qualifications and requested privileges of medical practitioners engaged in substance abuse rehabilitation and addiction treatment.

The form includes sections where the practitioner provides personal and professional details, including licenses, certifications, and qualifications relevant to substance abuse rehabilitation. It requires outlining the requested clinical privileges, covering areas such as addiction assessments, counseling, and treatment planning.

Important fields in this form include the practitioner's identification details, requested clinical privileges, and supporting documentation that showcases their expertise in substance abuse rehabilitation. Accurate completion of this form is essential to ensure that the practitioner is granted privileges aligned with their skill set and experience in addiction treatment.

Application Example: A licensed addiction counselor joining a military medical facility would utilize DA Form 5440-58 to request clinical privileges. By accurately completing the form and providing necessary documentation, the counselor's proficiency in substance abuse rehabilitation is evaluated, enabling the medical facility to grant appropriate privileges for addiction assessments and counseling.

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

Related Form: DA Form 5440-57, 5440-6, 5440-7, and 5440-8 are related forms intended for different medical specialties, each tailored for specific clinical privileges.