DA Form 5440-21: Physical Therapy Privileges PDF Guide – DA Form 5440-21 is the official U.S. Army form used to request, review, and approve clinical privileges for physical therapists (PTs) practicing in military treatment facilities (MTFs). It ensures that Army physical therapists operate within their demonstrated competencies, training, and the facility’s mission requirements, in accordance with AR 40-68, Clinical Quality Management.
This form standardizes the credentialing process for physical therapists, supporting high-quality, safe patient care for service members, families, and other beneficiaries.
Why DA Form 5440-21 Matters for Army Physical Therapists?
Physical therapists in the Army often function with expanded scope of practice, including direct access care for musculoskeletal conditions. This form delineates:
- Routine (Category I) privileges expected of a graduate-level PT.
- Special (Category II) privileges that require additional documented training and experience.
Privileging protects patients, supports provider professional development, and aligns with DoD and Army quality management standards. It is part of the broader credentialing and privileging system that applies to all healthcare providers in Army MTFs.
Key Benefits:
- Ensures competency-based practice.
- Facilitates advanced skills like ordering imaging, limited profiles, or specific interventions.
- Required for full practice authority in military settings.
How to Complete DA Form 5440-21? Step-by-Step Instructions
The form (dated FEB 2004) is a two-page document available as a fillable PDF.
Provider (Physical Therapist) Responsibilities (Section I):
- Enter your Name (Last, First, MI), Rank/Grade, and Facility.
- For each privilege category, enter a Provider Code (1–5) in the REQUESTED column:
- 1 — Fully competent.
- 2 — Modification requested (attach justification).
- 3 — Supervision requested.
- 4 — Not requested (lack of expertise).
- 5 — Not requested (lack of facility support/mission).
- Category I: Routine evaluations and procedures (core PT skills).
- Category II (includes Category I): Advanced privileges such as:
- Electroneuromyographic (EMG) testing.
- Early intervention for high-risk infants.
- Request appropriate imaging studies.
- Recommend limited duty profiles (not to exceed 30 days).
- Assign quarters up to 72 hours.
- Refer to specialty clinics.
- Prescribe P&T committee-approved medications.
- Line through and initial any non-applicable items. Sign and date.
Supervisor Responsibilities (Section II):
- Review requests and enter Approved codes (1–5).
- Provide overall recommendation and signature.
Credentials Committee/Function (Section III):
- Final approval, modifications, or disapproval.
Important Note: Any changes to approved privileges require a new DA Form 5440-21.
Download DA Form 5440-21 PDF
Official Download: DA Form 5440-21 PDF from Army Publishing Directorate.
Always use the latest version from armypubs.army.mil for official use.
Context Within Army Credentialing (AR 40-68)
AR 40-68 governs the Army’s Clinical Quality Management Program. DA Form 5440-21 is one of several delineation forms (e.g., for PAs, OTs, physicians). It supports ongoing professional practice evaluation (OPPE/FPPE), licensure requirements, and risk management.
Army PTs benefit from unique privileges compared to many civilian settings, including:
- Direct access for many musculoskeletal issues.
- Ability to order imaging and limited medications in approved contexts.
- Profile and duty restrictions authority.
This expanded role enhances readiness by reducing reliance on physicians for routine cases.
Who Needs This Form?
- Active Duty, Reserve, and National Guard physical therapists.
- Civilian PTs working in Army MTFs.
- Providers seeking initial or renewed privileges during credentialing cycles.
Related Forms:
- DA Form 5441-21 (Evaluation of Clinical Privileges – Physical Therapy).
- Other DA 5440 series forms for different specialties.
Best Practices for Successful Privileging
- Document all training, continuing education, and experience thoroughly.
- Align requests with facility capabilities and mission needs.
- Maintain current state licensure (one unrestricted license is typically sufficient for DoD practice).
- Prepare for periodic re-privileging and performance reviews.
For questions, consult your facility’s Credentials Office, Medical Staff Services, or refer directly to AR 40-68.
Stay Compliant and Current
Military healthcare standards evolve. Check armypubs.army.mil regularly for form updates and consult local policy for facility-specific privileging lists.
Ready to request or renew your physical therapy clinical privileges?
Download the form today and work with your supervisor and credentials committee for smooth approval.