DA Form 5440-6. Delineation of Clinical Privileges-Optometry Service

DA Form 5440-6 is designed for the delineation of clinical privileges within the Optometry Service. This form facilitates the documentation and evaluation of a medical practitioner's qualifications and requested privileges related to optometric care and eye health.

The form comprises sections where the practitioner provides their personal and professional details, including licenses, certifications, and qualifications. It also requires outlining the requested clinical privileges, covering areas such as comprehensive eye exams, vision correction, and ocular disease management.

Important fields in this form include the practitioner's identification information, requested clinical privileges, and supporting evidence of their expertise in optometric care. Accurate completion of this form is crucial to ensure that the practitioner is granted privileges that align with their proficiency in providing eye health services.

Application Example: A licensed optometrist joining a military medical facility would use DA Form 5440-6 to request clinical privileges. By accurately completing the form and submitting necessary documentation, the optometrist's proficiency in eye health care is evaluated, enabling the medical facility to grant appropriate privileges for comprehensive eye exams and vision correction.

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

Related Form: DA Form 5440-57, 5440-58, 5440-7, and 5440-8 are related forms intended for different medical specialties, each catering to specific clinical privileges.