DA Form 5441-3. Evaluation of Clinical Privileges-Internal Medicine

DA Form 5441-3 serves as a significant document for evaluating clinical privileges within the field of Internal Medicine. This form is crucial for assessing and establishing the qualifications and requested privileges for medical practitioners involved in providing comprehensive medical care for adult patients.

The form includes sections where the medical practitioner provides personal and professional details, including licenses, certifications, and qualifications specific to internal medicine practice. It requires outlining the requested clinical privileges, covering areas such as patient assessments, diagnostic evaluations, and treatment planning.

Key fields in this form include the practitioner's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in internal medicine. Accurate completion of this form is paramount to ensure that the practitioner is granted privileges aligned with their proficiency in delivering comprehensive adult medical care.

Application Example: A board-certified internist joining a military medical facility would utilize DA Form 5441-3 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in diagnosing and treating adult medical conditions 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 5441-28, 5441-29, 5441-30, and 5441-31 are related forms intended for different clinical privilege evaluation processes.