DA Form 5441-12. Evaluation of Clinical Privileges - Diagnostic Radiology

DA Form 5441-12 serves as a vital document for evaluating clinical privileges within the field of Diagnostic Radiology. This form is essential for assessing and establishing the qualifications and requested privileges for radiologists involved in diagnostic imaging and interpretation.

The form includes sections where the radiologist provides personal and professional details, including licenses, certifications, and qualifications specific to diagnostic radiology. It necessitates outlining the requested clinical privileges, covering areas such as X-ray, MRI, CT scan interpretation, and radiology reporting.

Key fields in this form include the radiologist's identification information, requested clinical privileges, and supporting evidence of their expertise in diagnostic radiology. Accurate completion of this form is crucial to ensure that the radiologist is granted privileges aligned with their proficiency in interpreting diagnostic imaging.

Application Example: A board-certified radiologist joining a military medical facility would use DA Form 5441-12 to request clinical privileges. By accurately completing the form and providing necessary documentation, the radiologist's proficiency in diagnostic imaging interpretation is evaluated, enabling the medical facility to grant appropriate privileges.

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

Related Form: DA Form 5441-11, 5441-13, 5441-14, and 5441-15 are related forms intended for different clinical privilege evaluation processes.