DA Form 5440-22: Delineation of Clinical Privileges Guide

DA Form 5440-22: Delineation of Clinical Privileges Guide – Military healthcare professionals in the U.S. Army must navigate a structured credentialing and privileging process to ensure patient safety and high-quality care. DA Form 5440-22, titled Delineation of Clinical Privileges, plays a key role in this system, particularly for providers without a dedicated specialty-specific form.

What Is DA Form 5440-22?

DA Form 5440-22 is an official U.S. Army form (dated FEB 2004) used to request, review, and approve specific clinical privileges for healthcare providers. It falls under Army Regulation (AR) 40-68, Clinical Quality Management, with the Office of The Surgeon General (OTSG) as the proponent agency.

This is a general-purpose form for providers in specialties or roles that lack a tailored DA Form 5440 series variant (e.g., unlike forms for Family Practice, Internal Medicine, or Physician Assistants). It serves as a continuation sheet or primary document to outline the scope of practice a provider may exercise at a military treatment facility (MTF).

Download the official form here: DA Form 5440-22 PDF.

Purpose and Importance in Army Medicine

Clinical privileging grants a provider permission to perform specific procedures, treatments, and patient care activities based on their education, training, experience, licensure, and demonstrated competence. This process:

  • Protects patients by ensuring only qualified providers deliver care.
  • Aligns with Joint Commission standards and DoD/DHA policies on clinical quality management.
  • Supports credentialing committees, department chiefs, and commanders in making informed decisions.

In the Army, privileging ties directly to AR 40-68, which governs the full lifecycle of provider qualifications, performance reviews, and adverse actions. Recent Military Health System (MHS) updates (effective 2025) streamline transfers, allowing providers to retain privileges across facilities with minimal re-processing.

How to Complete DA Form 5440-22? Step-by-Step Instructions

The form is two pages and includes clear instructions for providers and supervisors.

Section I – Clinical Privileges (Provider Responsibilities)

  1. Enter Provider Information: Name (Last, First, MI), Rank/Grade, and Facility.
  2. Code Each Privilege:
    • Use Provider Codes in the “REQUESTED” column:
      • 1: Fully competent (justification attached).
      • 2: Modification requested.
      • 3: Supervision requested.
      • 4: Not requested (lack of expertise).
      • 5: Not requested (lack of facility support).
  3. Line through non-applicable items and initial them.
  4. Provide comments or justifications as needed.
  5. Sign and date at the bottom.

Supervisor/Reviewer Responsibilities

  • Review requests and enter Approval Codes in the “APPROVED” column (mirroring provider codes with recommendations).
  • Provide overall recommendation (Approval as requested, with modifications, or disapproval) in Section II.
  • Sign as Department/Service Chief.

Additional Approvals

  • Section III: Credentials Committee/Function reviews and recommends.
  • Final approval rests with the facility commander or designated privileging authority.

Key Tip: Any changes to approved privileges require a new DA Form 5440-22 submission.

Who Uses DA Form 5440-22?

  • Physicians and other licensed independent practitioners in non-standard specialties.
  • Providers transitioning roles or facilities where a general delineation is appropriate.
  • Support for initial granting, renewal (typically every 2–3 years under current MHS policies), and modifications.

It works alongside other DA 5440-series forms and integrates with the Joint Centralized Credentials Quality Assurance System (JCCQAS) for tracking.

  • Credentialing vs. Privileging: Credentialing verifies qualifications (licenses, certifications, education). Privileging defines what the provider can actually do at the facility.
  • Performance Reviews: Ongoing Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) support privilege maintenance.
  • Recent Changes: MHS-wide reforms reduce administrative burden for transfers, emphasizing system-wide privileging.

Pro Tips for Providers:

  • Attach supporting documentation (e.g., training logs, case logs, proctoring evaluations).
  • Be realistic in requests—over-requesting without justification can delay approval.
  • Consult your facility’s Medical Staff Office or Credentials Coordinator early.

Why This Matters for Patient Care and Careers?

Accurate delineation of clinical privileges ensures alignment between provider capabilities and facility resources, reducing risk and enhancing readiness. For Army healthcare professionals, mastering this process supports smooth assignments, deployments, and career progression within the Military Health System.

For the most current guidance, refer to official Army Publishing Directorate resources, AR 40-68, and your local MTF policies. Always use the latest form version from armypubs.army.mil.