DA Form 5440-10: Psychiatry Clinical Privileges Guide – If you are a psychiatrist, behavioral health provider, or medical administrator in the U.S. Army, understanding DA Form 5440-10 is essential for credentialing and practicing within military treatment facilities (MTFs). This form standardizes the process for requesting and granting clinical privileges in psychiatry, ensuring providers meet qualifications based on training, experience, and competency while aligning with Army standards for patient safety and quality care.
What Is DA Form 5440-10?
DA Form 5440-10, titled Delineation of Clinical Privileges – Psychiatry, is an official U.S. Army form used to document and approve the scope of practice for psychiatrists and related providers. It falls under Army Regulation (AR) 40-68, Clinical Quality Management, with the Office of The Surgeon General (OTSG) as the proponent agency.
The current version (February 2004) remains available through official Army Publications channels. Providers use it to request specific privileges, supervisors review and recommend approvals, and credentials committees make final determinations.
Download the official form here: DA Form 5440-10 PDF
Who Uses DA Form 5440-10?
- Army psychiatrists (active duty, reserve, civilian, or contract providers) working in MTFs.
- Behavioral health professionals seeking delineated privileges in psychiatry subspecialties.
- Medical staff administrators, department chiefs, and credentials committees responsible for privileging.
It ensures only qualified individuals perform psychiatric assessments, treatments, and specialized procedures in military settings.
Key Sections and Structure of the Form
The form uses a structured coding system for requests and approvals:
Provider Codes (Requested column):
- 1: Fully competent
- 2: Modification requested (with justification)
- 3: Supervision requested
- 4: Not requested (lack of expertise)
- 5: Not requested (lack of facility support/mission)
Supervisor Codes (Approved column): Mirror the provider codes for recommendations.
Clinical Privilege Categories
- Category I: Physicians with experience in mental disorders but limited/no psychiatry residency (general practice level).
- Category II: Includes Category I + board-eligible psychiatrists.
- Category III: Includes I & II + board-certified by the American Board of Psychiatry and Neurology (ABPN) or equivalent.
- Category IV: Includes I-III + advanced fellowship training in subspecialties.
Core Privileges cover:
- Assessment and diagnosis of mental disorders
- Inpatient psychiatric treatment
- Alcohol/substance abuse treatment (including residential)
- Adult, child/adolescent, family, group, and marital psychotherapy
- Psychopharmacotherapy
- Somatic therapies (e.g., ECT, biofeedback, Amytal interview)
Subspecialties include:
- Child Psychiatry
- Forensic Psychiatry
- Geriatric Psychiatry
- Psychoanalysis / Child Psychoanalysis
- Addictions Medicine
- Consultant-Liaison Psychiatry
- Administrative Psychiatry
- Psychopharmacology
Additional Areas:
- Command consultations (e.g., command-directed evaluations, psychological autopsies)
- Specialized skills (behavior therapy, hypnotherapy, dangerousness evaluations)
- Research and other specified privileges.
Step-by-Step Process for Completing and Submitting DA Form 5440-10
- Provider Completion — Fill in personal details (name, rank, facility). Request privileges using the codes. Sign Section I.
- Supervisor Review — Department/Service Chief reviews, codes approvals, and provides recommendations in Section II.
- Credentials Committee — Reviews and recommends in Section III.
- Final Approval — Commander or designated authority grants privileges.
- Maintenance — Privileges require periodic review/renewal per AR 40-68. Submit a new form for any changes.
Tip: Attach supporting documentation (e.g., board certification, fellowship completion, case logs) for higher categories or subspecialties.
Why Proper Privileging Matters in Army Psychiatry?
Clinical privileging protects patients, supports mission readiness, and complies with federal standards (including Joint Commission and DoD requirements). It allows tailored scopes of practice in diverse settings—from garrison clinics to deployed environments—while maintaining high standards of care for service members, families, and retirees.
Board certification (ABPN) and relevant fellowships strengthen applications for Category III/IV and subspecialty privileges.
Common Questions (FAQs)
Is DA Form 5440-10 still current?
Yes, it is the active form listed in official Army resources for psychiatry privileging under AR 40-68.
Can civilian providers use it?
Yes, civilian and contract psychiatrists in Army MTFs must complete it for credentialing.
How often are privileges renewed?
Typically every two years or as specified by local credentials policy and AR 40-68.
Where to get help?
Contact your MTF Credentials Office, Medical Staff Services, or Behavioral Health Department Chief.
Download and Resources
- Official Form: DA Form 5440-10
- Governing Regulation: AR 40-68 Clinical Quality Management (available via Army Publishing Directorate).
For the most accurate guidance, consult your local MTF credentials committee, as facility-specific requirements may apply.