Af Form 1540 PDF Details

The AF Form 1540 is authorized under Title 10, U.S.C., Chapter 55, Sections 1094 and 1102. It evaluates applicants for medical staff membership and clinical privileges at Air Force medical facilities and affiliated civilian healthcare organizations.

The form collects the following information:

Completing AF Form 1540 is voluntary, but inaccuracies or omissions may lead to denial or revocation of clinical privileges. The Air Force uses the form to share applicant credentials with government boards, professional societies, and other healthcare organizations.

For civilian healthcare credentialing, see the Credentialing Application. To document clinical training history, use the Clinical Experience Form.

QuestionAnswer
Form NameAf Form 1540
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesaf form 1540 2013 fillable, af 1540, af 1541 fillable, af form 1541 fillable

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APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT

AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102.

PRINCIPAL PURPOSE: To evaluate professional criteria for medical staff membership and clinical privileges; designed to help establish an applicant’s background, current competence, and physical and mental ability to discharge patient care responsibilities. This evaluation is essential to establishing and maintaining a qualified, competent medical staff.

ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force.

DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges.

APPLICANT COMPLETES SECTIONS I THROUGH X

I.

IDENTIFICATION (All date entries must be entered as MM/DD/YYYY)

NAME (Last, First, Middle Name)

DATE OF BIRTH

GRADE

SSN

DATE

ALIAS (i.e., Maiden)

 

 

 

 

HOME ADDRESS (City, State, and Zip Code)

HOME PHONE

DUTY PHONE

EMAIL ADDRESS

 

 

 

 

 

 

ORGANIZATION/OFFICE SYMBOL

DUTY SECTION

DAFSC

PAFSC

CORPS

SOURCE OF ACCESSION:

Baccalaureate Degree Completion Program (BDCP)

Direct Accession (DA)

Enlisted Commissioning Program (ECP)

Financial Assistance Program (FAP)

Health Professional Scholarship Program (HPSP)

Reserve Officer Training Corps (ROTC)

Uniformed Services Univ. of Health Sciences (USUHS)

National Guard

Reserve

Foreign National

Civilian Civil Service

Civilian Contractor

Civilian Consultant

Civilian Volunteer

Other:

II.

PROFESSIONAL EDUCATION (Undergraduate/Graduate/Professional)

 

 

 

 

 

 

 

 

NAME OF PROFESSIONAL SCHOOL

LOCATION

DATES ATTENDED

 

DEGREE

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.

POST GRADUATE TRAINING (Internship, Residency, Fellowship)

 

 

NAME OF INSTITUTION

LOCATION

TYPE OF PROGRAM

DATES ATTENDED

(Residency, etc.)

FROM

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV.

PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS (If additional space is needed, continue on Page 2)

 

 

 

NAME OF MEDICAL TREATMENT FACILITY (MTF) OR ORGANIZATION

LOCATION

SERVICE OR SPECIALTY

TO WHICH ASSIGNED

DATES ASSIGNED

FROM

TO

 

 

AF FORM 1540, 20040819 (EF-V1)

PREVIOUS EDITION IS OBSOLETE

PAGE 1 OF 4 PAGES

APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT (Continued)

IV.

PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS (Continued) (If additional space is needed, continue in Remarks, Page 4)

NAME OF MEDICAL TREATMENT FACILITY (MTF) OR ORGANIZATION

LOCATION

SERVICE OR SPECIALTY

TO WHICH ASSIGNED

DATES ASSIGNED

FROM

TO

 

 

V. LICENSE/CERTIFICATION/REGISTRATION, SPECIALTY, AND FEDERAL DEA/STATE CSR (If additional space is needed, continue in Remarks, Page 4)

LICENSE/CERTIFICATION/REGISTRATION (Must list ALL ever held.)

STATE LICENSE (Name of State)

LICENSE NUMBER

DATE ISSUED

EXPIRATION DATE

 

 

 

 

 

 

 

 

NATIONAL CERTIFICATION

CERTIFICATE NUMBER

DATE ISSUED

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL REGISTRATION

REGISTRATION NUMBER

DATE ISSUED

EXPIRATION DATE

SPECIALTY DATA

SPECIALTY (List all specialties for which fully qualified)

BOARD CERTIFICATION (Specialty Board)

CERTIFICATE NUMBER

DATE ISSUED

EXPIRATION DATE

FEDERAL DRUG ENFORCEMENT ADMINISTRATION (DEA)/STATE CONTROLLED SUBSTANCE REGISTRATION (CSR)

FEDERAL DEA (Type)

REGISTRATION NUMBER

DATE ISSUED

EXPIRATION DATE

DoD Fee-Exempt

Federal (Fee-Paid)

STATE CSR (Name of State)

REGISTRATION NUMBER

DATE ISSUED

EXPIRATION DATE

VI.

MEMBERSHIP IN PROFESSIONAL SOCIETIES (If additional space is needed, continue in Remarks, Page 4)

 

 

 

 

 

 

NAME OF SOCIETY

 

STATUS (Member, Fellow, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VII. REFERENCES (Every applicant MUST list three references: former clinical supervisor; chief, medical staff (SGH); and peer) (List email address if available)

NAME

ADDRESS (City/Base, State, Zip Code)

TELEPHONE/EMAIL ADDRESS

( ) −

( ) −

( ) −

AF FORM 1540, 20040819 (EF-V1)

PREVIOUS EDITION IS OBSOLETE

PAGE 2 OF 4 PAGES

APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT (Continued)

VIII.

PRACTICE HISTORY (Explain all “yes” responses in Remarks, Page 4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

YES

 

NO

A. Have there been previously successful or currently pending

 

 

 

 

 

 

E. Have you ever been a defendant or the subject of a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

challenges, revocations, or restrictions to any license, certification,

 

 

 

 

 

 

medical malpractice liability claim, settlement,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or registration (state, district or Drug Enforcement Administration) to

 

 

 

 

judicial or administrative adjudication, or any other

 

 

 

 

 

practice in any jurisdiction, or the voluntary/involuntary

 

 

 

 

resolved or unresolved allegations of inappropriate,

 

 

 

 

 

relinquishment of such license, certification, or registration?

 

 

 

 

unethical, unprofessional, or substandard care?

 

 

 

 

 

B. Have you ever had a voluntary or involuntary limitation, reduction,

 

 

 

 

 

 

IF “YES” WAS THE RESPONSE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

revocation, suspension, denial, or loss of clinical privileges?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Have you ever voluntarily or involuntarily terminated or been denied

 

 

 

 

 

 

(1)

Settled prior to final court action?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medical staff membership or membership in a professional group or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

society?

 

 

 

 

 

 

 

(2)

Judgment rendered by the court?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Have you ever been a defendant in a felony or a misdemeanor case?

 

 

 

 

 

 

(3)

Defendant found liable?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Indicate final disposition of case in Remarks, Page 4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

Matter still pending?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IX.

HEALTH STATUS (Explain all “yes” responses in Remarks, Page 4)

 

 

 

 

YES

 

NO

 

 

YES

A. Do you currently have any physical or mental impairment that

 

 

 

 

 

 

E. Have you ever been hospitalized for, or diagnosed

 

 

 

could limit your clinical practice?

 

 

 

 

 

 

with, a psychiatric disorder to include substance

 

 

 

 

 

 

 

 

 

abuse?

 

 

 

 

 

 

 

 

 

 

 

B. Are you currently taking any medications?

 

 

 

 

 

 

F. Are you currently under or have you ever received

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

treatment for an alcohol or drug-related condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Do you have a potentially communicable disease?

 

 

 

 

 

 

G. Have you ever used a controlled substance that was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

not prescribed for you by a physician or other health

 

 

 

 

 

 

 

 

 

 

 

D. Have you ever been hospitalized for any reason in the past 5 years?

 

 

 

 

 

 

care provider?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

X.

STATEMENT OF APPLICANT (PLEASE READ CAREFULLY BEFORE SIGNING)

I certify all information submitted by me in this application is true to the best of my knowledge and belief and I have the ability to perform the clinical privileges requested.

I certify that any false or incomplete information knowingly provided on or with this application may be grounds either for not employing or accessing me or for dismissing or releasing me if I am already employed or serving. I understand that knowingly providing false or incomplete information is punishable by fine or imprisonment under United States Code Title 18, Section 1001.

I understand and agree that I, as an applicant for clinical privileges, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.

I authorize all who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information to the designated healthcare organization, their staff, and agents. This includes individuals, institutions, and entities of organizations with which I am currently or have been associated, and all professional liability insurers with which I have had or currently have professional liability insurance.

I consent to the inspection of all records and documents pertinent to my licensure, specific training, experience, current competence, and ability to perform the privileges requested, and, if requested, appear for an interview.

I agree to release and hold harmless from any liability the United States and any and all persons who participate within the scope of their duties in good faith and without malice in the review of any action or recommendation relating to my application.

In making this application for clinical privileges, I acknowledge my responsibility to provide for the continuous care of my patients.

I have been informed that the medical staff bylaws, rules, and regulations (AFI 44-119, Clinical Performance Improvement) can be accessed at the following internet site: http://www.e-publishing.af.mil/ and agree that my activities as a medical staff member will be bound by these bylaws.

I acknowledge that I am familiar with the principles and standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and will cooperate in maintaining JCAHO standards.

I agree to subject my clinical performance to, and faithfully participate in, activities to measure, assess, and improve performance on an organization-wide basis.

SIGNATURE OF APPLICANT

DATE

AF FORM 1540, 20040819 (EF-V1)

PREVIOUS EDITION IS OBSOLETE

PAGE 3 OF 4 PAGES

APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT (Continued)

FOR CREDENTIALS FUNCTION USE ONLY

TYPE OF CLINICAL PRIVILEGES

Regular Privileges

Supervised Privileges

TYPE OF MEDICAL STAFF APPOINTMENT

Temporary Privileges

Initial-Active Medical Staff Appointment

Active Medical Staff Appointment

No Medical Staff Appointment

Initial-Affiliate Medical Staff Appointment

Affiliate Medical Staff Appointment

Temporary Medical Staff Appointment

 

 

 

XI.

CLINICAL SUPERVISOR RECOMMENDATION

 

 

 

 

I have reviewed the provider’s clinical privileges and confirm his/her physical and mental ability and qualifications to perform the requested privileges.

CLINICAL PRIVILEGES:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

 

 

MEDICAL STAFF APPOINTMENT:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

SIGNATURE OF CLINICAL SUPERVISOR (USE NAME STAMP OR TYPE NAME AND TITLE)

 

DATE

 

 

 

 

 

XII.

 

DEPARTMENT CHAIR / CHIEF OF SERVICE RECOMMENDATION

 

 

 

 

 

 

 

CLINICAL PRIVILEGES:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

 

 

MEDICAL STAFF APPOINTMENT:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

SIGNATURE OF DEPARTMENT CHAIR / CHIEF OF SERVICE (USE NAME STAMP OR TYPE NAME AND TITLE)

 

DATE

 

 

 

 

 

XIII.

CREDENTIALS FUNCTION CHAIRPERSON (SGH) RECOMMENDATION

 

 

 

 

 

 

 

CLINICAL PRIVILEGES:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

 

 

MEDICAL STAFF APPOINTMENT:

Approval

Approval with Modification 1

Disapproval 1

 

 

 

SIGNATURE OF CREDENTIALS FUNCTION CHAIRPERSON (USE NAME STAMP OR TYPE NAME AND TITLE)

 

DATE

 

 

 

 

 

XIV.

MEDICAL FACILITY COMMANDER APPROVAL

 

 

 

 

 

 

Approved

Approved with Modification 1

Disapproved 1

 

 

 

SIGNATURE OF MEDICAL FACILITY COMMANDER (USE NAME STAMP OR TYPE NAME AND TITLE)

 

DATE

 

 

 

 

REMARKS (If additional space is needed, continue on plain bond paper):

(NOTE:1 Explain in “Remarks” on this page)

AF FORM 1540, 20040819 (EF-V1)

PREVIOUS EDITION IS OBSOLETE

PAGE 4 OF 4 PAGES

How to Edit Af Form 1540 Online for Free

FormsPal's online PDF editor lets you complete AF Form 1540 directly in your browser without downloading any software. Follow these steps to fill out the Application for Clinical Privileges and Medical Staff Appointment.

Steps to Fill Out AF Form 1540

Step 1: Click the "Get Form" button at the top of this page to open AF Form 1540 in the online editor. The form will load in your browser and you can begin entering information right away.

Step 2: Start by completing Section I (personal information) and Section II (professional background). Include your full name, date of birth, social security number, and contact information. Section II asks for your educational background, internship or residency programs, and post-graduate training details:

How to fill out AF Form 1540 Section I and Section II - personal and professional information

Step 3: Complete Section III for post-graduate training. Enter all present and previous military and civilian assignments. For each position, include the name of the medical treatment facility or organization, location, service or specialty, and dates assigned:

Post-graduate training and military assignment history fields in AF Form 1540

Confirm the edition and page numbering information at the top of each page. The form header includes fields for edition version and page count:

Edition version and page numbering fields in AF Form 1540

Step 4: Fill in your license, certification, and registration details in Section V. For each entry, provide the state or certifying organization, license or certificate number, issue date, and expiration date. Also complete the Federal Drug Enforcement Administration (DEA) registration and state controlled substances registration fields if applicable:

Licensure, certification, and DEA registration fields in AF Form 1540

Step 5: Complete the specialty data section. List all clinical specialties and board certifications, including the specialty board name, certificate number, issue date, and expiration date. Also fill in DEA fee-exempt status and state controlled substances registration details:

Specialty data and board certification section in AF Form 1540

Step 6: Review all entries carefully. Any omission or error may result in denial or revocation of clinical privileges. Click "Done" to save your completed AF Form 1540. Create a free FormsPal account to download, print, or electronically share the form.

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