DA Form 5440-13: General Surgery Clinical Privileges Guide

DA Form 5440-13: General Surgery Clinical Privileges Guide – DA Form 5440-13 is the official U.S. Army form used to request, review, and grant clinical privileges for general surgeons in military treatment facilities (MTFs). It standardizes the scope of practice for providers performing general surgery procedures, ensuring patient safety and compliance with Army regulations.

This form remains current as of its February 2004 edition and is prescribed under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency.

Why DA Form 5440-13 Matters for Army General Surgeons?

In the U.S. Army Medical Department, clinical privileges define exactly what procedures a surgeon can perform independently, with supervision, or not at all. The form supports credentialing, privileging, and re-privileging processes at military hospitals and clinics worldwide.

Key purposes include:

  • Documenting a surgeon’s requested and approved competencies.
  • Categorizing privileges by complexity (Categories I–IV).
  • Supporting quality assurance, risk management, and compliance with Joint Commission standards adapted for military settings.
  • Facilitating transfers or deployments by clearly outlining a provider’s scope of practice.

Download the official PDF directly here: DA Form 5440-13 PDF.

Structure of DA Form 5440-13

The form includes clear instructions for both the provider and supervisor:

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):

  • Similar scale, with supervisor recommendations to the approving authority (usually the commander or credentials committee).

Privilege Categories (I–IV)

The form defines four escalating levels of general surgery privileges based on patient risk and provider experience:

  • Category I: Uncomplicated cases with no serious threat to life. Suitable for physicians without formal surgical training if prior privileges and success are documented.
  • Category II: Includes Category I plus more complex procedures (may require general or conductive anesthesia). Requires at least one year post-PGY1 surgical training or equivalent experience.
  • Category III: Includes I & II plus complex/severe illnesses and life-threatening conditions. Providers act as consultants and should pursue board certification eligibility.
  • Category IV: Highest level, including subspecialty-level expertise. Providers serve as top consultants.

Core General Surgery Privileges Listed on the Form

The form provides a comprehensive (but not exhaustive) list of procedures. Providers must code each one. Examples include:

Diagnostic & Basic Procedures:

  • Moderate sedation
  • Introduction of radiologic contrast materials
  • Various endoscopies (bronchoscopy, EGD, colonoscopy, etc.)

Head & Neck / Breast / Chest:

  • Thyroid/parathyroid procedures
  • Mastectomies and axillary dissections

Abdominal & Laparoscopic:

  • GI tract operations (esophagus to anus)
  • Biliary tract surgery
  • Laparoscopic procedures (hernia repair, appendectomy, bariatric, anti-reflux, etc.)
  • Hernia repairs with prosthetics

Trauma & Critical Care:

  • Initial stabilization and emergent management of trauma patients
  • Intensive care management (catheters, ventilators, vasoactive meds)

Other:

  • Pediatric general surgery (common cases)
  • Sentinel lymph node biopsy
  • Laser use (with additional documentation)
  • Skin/soft tissue procedures, including grafts and lymph node dissections

Separate sections cover General Thoracic Surgery and General Vascular Surgery privileges (e.g., lobectomy, aneurysm repair, arteriography).

Note: Laser privileges require specific training documentation and MTF policy acknowledgment.

How to Complete and Submit DA Form 5440-13?

  1. Provider Section (Section I): Fill in personal info, request codes for each privilege, initial non-applicable items, and sign.
  2. Supervisor Review (Section II): Supervisor assigns approval codes and provides overall recommendation.
  3. Comments Section: Explain any variances or modifications.
  4. Subspecialties: Initial any additional areas (e.g., vascular, colorectal) and attach separate forms if needed.
  5. Route through the credentials committee for final commander approval.

Revisions require a new form. Providers must demonstrate ongoing competence through case logs, training, and performance reviews during re-privileging.

Who Uses This Form?

  • Active Duty, Reserve, and National Guard general surgeons
  • Civilian surgeons working in Army facilities under contract or partnership
  • Medical residents and fellows in Army training programs (with appropriate supervision levels)
  • Providers transitioning between duty stations or deploying

Similar delineation processes exist in other services (e.g., Air Force, Navy) and civilian hospitals, but DA Form 5440-13 is specific to Army standards.

  • AR 40-68: Primary regulation for Army clinical quality management.
  • Army Publishing Directorate (armypubs.army.mil) for the latest forms.
  • Maintain detailed procedure logs, CME, and board certification status for successful privileging.
  • For laser or advanced procedures, prepare extra documentation early.

Pro Tip for Army Surgeons: Align your requested privileges with your training, experience, and the mission needs of your facility to avoid delays in approval.

Stay Compliant and Current

Clinical privileging protects patients and providers alike. Always use the official form from Army Publishing and consult your local Medical Treatment Facility (MTF) credentials office for guidance specific to your command.

For the most authoritative source, visit the official download link: DA Form 5440-13.