DA Form 5441-21. Evaluation of Clinical Privileges - Physical Therapy

DA Form 5441-21 is utilized for evaluating clinical privileges in the field of Physical Therapy. This form plays a crucial role in assessing and establishing the qualifications and requested privileges for licensed physical therapists involved in providing rehabilitative and therapeutic services.

The form comprises sections where the physical therapist provides personal and professional details, including licenses, certifications, and qualifications specific to physical therapy practice. It necessitates outlining the requested clinical privileges, covering areas such as therapeutic assessments, treatment planning, and patient rehabilitation.

Key fields in this form include the physical therapist's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in physical therapy. Accurate completion of this form is vital to ensure that the physical therapist is granted privileges aligned with their proficiency in delivering rehabilitative and therapeutic interventions.

Application Example: A licensed physical therapist joining a military medical facility would utilize DA Form 5441-21 to request clinical privileges. By accurately completing the form and providing necessary documentation, the therapist's proficiency in therapeutic assessments and rehabilitation 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 5441-22, 5441-23, 5441-24, and 5441-25 are related forms intended for different clinical privilege evaluation processes.