DA Form 5441-22. Evaluation of Clinical Privileges

DA Form 5441-22 serves as a generic form for evaluating clinical privileges. This form provides flexibility for accommodating various medical and healthcare professions that require privilege evaluations based on individual qualifications and expertise.

The form includes sections where the practitioner provides personal and professional details, including licenses, certifications, and qualifications specific to their medical or healthcare profession. It requires outlining the requested clinical privileges, which would vary based on the particular field of practice.

Important fields in this form include the practitioner's identification information, requested clinical privileges, and supporting evidence of their qualifications. Accurate completion of this form is essential to ensure that the practitioner is granted privileges aligned with their specific area of expertise.

Application Example: A medical practitioner with a unique specialization joining a military medical facility for which no specific DA Form exists would utilize DA Form 5441-22. By accurately completing the form and providing necessary documentation, the practitioner's qualifications and requested clinical privileges are 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 5441-21, 5441-23, 5441-24, and 5441-25 are related forms intended for different clinical privilege evaluation processes.