DA Form 5440-3: Internal Medicine Clinical Privileges Guide

DA Form 5440-3: Internal Medicine Clinical Privileges Guide – Internal medicine physicians serving in the U.S. Army play a critical role in delivering high-quality care to service members, families, and beneficiaries. DA Form 5440-3, titled Delineation of Clinical Privileges—Internal Medicine, is the official document used to request, review, and grant specific clinical privileges for these providers within Army medical facilities.

This form ensures that only qualified physicians perform procedures and manage patients according to their training, experience, and demonstrated competence, in full compliance with Army Regulation (AR) 40-68, Clinical Quality Management.

What Is DA Form 5440-3?

DA Form 5440-3 is a standardized U.S. Army form (dated February 2004, with previous editions obsolete) that allows Internal Medicine physicians to delineate the scope of their clinical practice. It lists categories of privileges such as:

  • Ambulatory and inpatient care
  • Diagnostic procedures
  • Management of complex medical conditions
  • Consultative services
  • Specific interventions common in internal medicine (e.g., lumbar puncture, paracentesis, thoracentesis, central line placement, and more advanced procedures depending on the facility and provider qualifications)

Providers mark their requested level of competence (typically coded as 1 – Fully competent, with options for limited or supervised practice). Supervisors review and recommend approvals, and a credentials committee or commander grants final privileges.

The form works in conjunction with related DA Form 5440 series documents for other specialties and supports ongoing privileging, re-privileging, and any modifications to scope of practice.

Download the Official Form Here:
DA Form 5440-3 PDF

Who Uses DA Form 5440-3?

  • Active Duty Army Medical Corps Officers (MD/DO) specializing in Internal Medicine (often 61F area of concentration).
  • Civilian physicians working in Army Medical Treatment Facilities (MTFs) under contract or as GS employees.
  • Resident physicians and fellows advancing in their training.
  • Providers seeking initial appointment, renewal (typically every 2 years), or changes in privileges.

It applies across Army hospitals, clinics, and deployed settings to maintain uniform standards of care.

Why Clinical Privileges Matter in the Army?

Privileging protects patients and providers by aligning practice with verified competency. AR 40-68 requires documentation of education, board certification (or eligibility), licensure, training, and proctored experience. This process supports:

  • Quality assurance and risk management
  • Compliance with Joint Commission and DoD standards
  • Safe delegation of procedures
  • Career progression for military physicians

Failure to maintain current privileges can limit deployment eligibility or assignment options.

How to Complete DA Form 5440-3? Step-by-Step

  1. Provider Section — Fill in name, rank/grade, facility, and personal details.
  2. Requested Privileges — Review each category and procedure. Enter the appropriate code for what you request (e.g., full, with consultation, or not requested). Line through and initial inapplicable items.
  3. Qualifications & Supporting Documents — Attach CV, licenses, board certificates, training logs, and letters of recommendation as required by your MTF credentials office.
  4. Provider Signature — Certify accuracy at the end of Section I.
  5. Supervisor Review — The department chief or supervisor reviews, marks approved items, and provides an overall recommendation in Section II.
  6. Credentials Committee & Commander Approval — Final review and granting of privileges.

Tip: Always check your local MTF bylaws or credentials manual for facility-specific criteria, as some procedures require additional proctoring or case logs.

Updates or changes to privileges require a new DA Form 5440-3 submission.

Common Privileges in Internal Medicine (Examples)

Typical categories on the form include:

  • Core ambulatory and inpatient management of adult patients
  • Critical care consultation (often in coordination with intensivists)
  • Procedural skills (e.g., arthrocentesis, bone marrow biopsy in some settings, endoscopy privileges if subspecialty-trained)
  • Management of chronic conditions (diabetes, hypertension, heart failure, etc.)
  • Preventive medicine and wellness services

Subspecialists (e.g., cardiology, gastroenterology, pulmonology) may use additional DA 5440 forms or addendums.

  • AR 40-68 Clinical Quality Management — Primary governing regulation.
  • Army Publishing Directorate (armypubs.army.mil) for all DA 5440 series forms.
  • Your MTF Credentials Manager or Medical Staff Office for guidance.
  • GoArmy.com for Internal Medicine Physician (61F) career information.

Stay Compliant and Current

Clinical privileging is an ongoing process. Providers must maintain unrestricted medical licenses, complete required CME, and participate in peer review and performance improvement activities. Army physicians benefit from robust GME programs and opportunities to practice across diverse settings—from garrison clinics to forward-deployed roles.

Need the form or assistance? Download it directly from the official Army source and consult your local credentials office for the most current instructions.