Da Form 5440 18 PDF Details

The DA Form 5440-18, titled "Delineation of Clinical Privileges - Physician Assistant," is a critical document within the U.S. Army medical system. It is governed by Army Regulation 40-68 (Clinical Quality Management), with oversight by the Office of The Surgeon General (OTSG). The form provides a formal process for physician assistants (PAs) to request and obtain clinical privileges, confirming their competence across primary care, specialty areas, procedures, and inpatient services.

Who Needs DA Form 5440-18?

This form is required for any physician assistant working within a U.S. Army medical treatment facility (MTF) who seeks authorization to perform specific clinical duties. It applies to:

The form ensures every PA's scope of practice is formally documented, reviewed by a supervisor, and approved before any patient care begins.

Clinical Privilege Categories Covered

DA Form 5440-18 organizes clinical privileges into four broad categories, each requiring documented evidence of competency:

The Approval Process

Obtaining clinical privileges through this form involves a structured, multi-step review:

  1. The PA completes the privilege request section, listing each privilege sought and providing documented evidence of training, case volume, and competency for each item
  2. A supervising physician or department chief reviews all requests, confirms or modifies each privilege based on direct observation and performance records, and signs the review section
  3. The credentials committee examines the completed form and may request additional documentation, a proctoring period, or direct observation before making a final decision
  4. Final approval is granted by the facility commander or designated authority, typically within 30 to 60 days of a complete submission

PAs may be granted temporary privileges during the credentialing review period, allowing supervised patient care to continue without interruption while the full process is completed.

Governing Regulations and Record Requirements

The form is governed by Army Regulation 40-68, which establishes credentialing and privileging requirements for all Army healthcare providers. OTSG provides policy oversight to ensure consistency across all military treatment facilities worldwide. Facilities must retain completed DA Form 5440-18 records for each PA for the duration of the provider's assignment, plus a minimum of two years after separation from the facility.

QuestionAnswer
Form NameDa Form 5440 18
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesexamples of physician telemedicine privilege forms, FEB, APD, radiographs

How to Edit Da Form 5440 18 Online for Free

Filling out DA Form 5440-18 correctly is essential for physician assistants who need to establish or update their clinical privileges at a U.S. Army medical treatment facility. The steps below explain each part of the process.

How to Fill Out the Form Step by Step

  1. Enter facility and unit information - At the top of the form, write the name and address of the military treatment facility (MTF), your unit designation, and the date of the request. Use the format your MTF's credentialing office requires.
  2. Provide your personal and professional information - Print your full name, rank, and DoD identification number as they appear in official records. Include your National Provider Identifier (NPI) number if you have one.
  3. List your requested clinical privileges - Review the privilege categories on the form and check each box for the privileges you are requesting. For each requested privilege, document the training source, the number of procedures you performed in the past 24 months, and any relevant certifications.
  4. Complete the attestation statement - Sign and date the attestation confirming that all information is accurate and that you meet the minimum competency requirements for each privilege you have selected.
  5. Submit for supervisor review - Present the form to your supervising physician or department head for review. Your supervisor will confirm, modify, or deny each privilege request and sign the form before it moves forward.
  6. Forward to the credentials office - Submit the signed form to the MTF credentials office along with any required supporting documents, such as training certificates, continuing medical education records, or case logs.
  7. Await the committee decision - The credentials committee reviews all materials and notifies you in writing of their decision. Approval, conditional approval with proctoring, or denial will be recorded in your credentials file.

What information must be included on the form?

The form requires your name, rank, DoD identification number, NPI, facility details, and a list of requested privileges with supporting documentation for each. Signatures from both you and your supervising physician are mandatory before submission.

How long does the credentialing process take?

Initial credentialing typically takes 30 to 60 days from the date of a complete submission. Temporary privileges may be granted during this period so that supervised patient care can continue while the full review is underway.

Can privileges be denied or revoked?

Yes. The credentials committee may deny a privilege request if the documentation does not demonstrate sufficient competency. Existing privileges may also be suspended or revoked after an adverse patient care event, a formal complaint, or a pattern of quality concerns identified through peer review. Revocation decisions are documented in the provider's credentials file.

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If you work with physician credentialing and healthcare documentation, these related forms may also be relevant to your work:

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