DA Form 5441-40. Evaluation of Clinical Privileges - Therapeutic Radiology

DA Form 5441-40 is intended for evaluating clinical privileges for Therapeutic Radiology professionals. This form plays a crucial role in assessing and establishing the qualifications and requested privileges for practitioners specializing in utilizing radiation therapy for treating cancer and other medical conditions.

The form comprises sections where the therapeutic radiologist provides personal and professional details, including licenses, certifications, and qualifications specific to therapeutic radiology practice. It requires outlining the requested clinical privileges, covering areas such as radiation treatment planning, treatment administration, and patient care coordination.

Important fields in this form include the therapeutic radiologist's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in radiation therapy. Accurate completion of this form is vital to ensure that the practitioner is granted privileges aligned with their proficiency in delivering radiation therapy for medical treatments.

Application Example: A licensed therapeutic radiologist joining a military medical facility would utilize DA Form 5441-40 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in radiation treatment planning and treatment administration 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 5441-37, 5441-38, 5441-39, and 5441-4 are related forms intended for different clinical privilege evaluation processes.