DA Form 5440a. Approval of Clinical Privileges/Staff Appointment

DA Form 5440a, also known as "Approval of Clinical Privileges/Staff Appointment," is used to request and document the approval of clinical privileges and staff appointments for medical practitioners. This form is crucial for establishing the qualifications and granting privileges to practitioners based on their expertise and professional background.

The form includes sections where the practitioner's qualifications, licenses, and certifications are outlined. It requires details about requested clinical privileges, such as medical procedures or services the practitioner is authorized to perform. Additionally, sections for approval and verification of credentials by authorized personnel are present.

Key fields in this form include the practitioner's identification information, requested clinical privileges, and a detailed account of their professional qualifications. Accurate completion is vital as it directly impacts the privileges granted to the practitioner, ensuring they are authorized to perform specific medical activities.

Application Example: A newly hired medical practitioner at a military medical facility would complete DA Form 5440a to request clinical privileges and staff appointment. By accurately completing the form and providing necessary documentation, the practitioner's qualifications and requested privileges are evaluated, enabling the medical facility to grant appropriate privileges and appointments.

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

Related Form: DA Form 5440-9, 5441, 5441-1, and 5441-10 are related forms intended for different clinical privilege evaluation processes.