DA Form 5440-31: Chiropractic Clinical Privileges Guide

DA Form 5440-31: Chiropractic Clinical Privileges Guide – If you are a chiropractor serving in the U.S. Army, Department of Defense (DoD), or Military Health System (MHS), understanding DA Form 5440-31 is essential for practicing within military treatment facilities (MTFs). This official Army form standardizes the process for requesting, reviewing, and granting clinical privileges to chiropractic providers.

What Is DA Form 5440-31?

DA Form 5440-31, titled Delineation of Clinical Privileges – Chiropractic, is a Department of the Army form used to define the scope of practice for chiropractors in military healthcare settings. It falls under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency.

The form ensures that chiropractors demonstrate competence based on education, training, and experience before providing care to active duty service members and other eligible DoD beneficiaries. It aligns with broader DoD and DHA policies on credentialing and privileging.

Current version: February 2004 (still in active use as the primary form for this purpose).

Official Download: DA Form 5440-31 PDF

Purpose of the Form

Clinical privileging in the military protects patient safety and ensures providers only perform services matching their verified skills and facility capabilities. For chiropractors, the form:

  • Documents requested and approved privileges.
  • Supports credentialing processes in MTFs.
  • Allows for modifications, supervision requirements, or limitations based on individual competence.
  • Facilitates integration of chiropractic services into the Military Health System for neuromusculoskeletal care.

Chiropractic care has grown in the DoD, helping manage back pain, spinal issues, and related conditions for service members, often reducing reliance on medications or surgery.

Key Sections of DA Form 5440-31

Section I – Clinical Privileges

Providers code each privilege as “Requested” using these codes:

  • 1 — Fully competent
  • 2 — Modification requested
  • 3 — Supervision requested
  • 4 — Not requested (lack of expertise)
  • 5 — Not requested (lack of facility support)

Supervisors then approve with matching codes.

Core Privileges Listed (summarized):

  • a. Provide chiropractic health care as taught in a Council on Chiropractic Education (CCE) accredited college to eligible DoD beneficiaries.
  • b/c. Perform manual/mechanical osseous and soft tissue procedures for axial and non-axial neuromusculoskeletal disorders.
  • d. Conduct history, physical, and chiropractic examinations (excluding vaginal exams).
  • e. Order standard plain film radiology (spine, skull, chest, ribs, pelvis).
  • f. Order basic lab tests (CBC, electrolytes, ESR, UA, etc.).
  • g. Use therapeutic modalities (heat, cold, ultrasound, etc.) and refer as needed.
  • h/i. Recommend limited duty profiles and assign quarters (up to 72 hours) per regulations.
  • j. Provide lifestyle, nutrition, exercise, and ergonomic counseling.
  • k. Order orthotic devices available in the MTF.

Privileges focus on conservative neuromusculoskeletal management and require demonstrated competence.

Sections II & III – Recommendations and Approvals

  • Supervisor (Department/Service Chief) provides recommendation.
  • Credentials Committee/Function reviews and recommends.
  • Final approval authority rests with the commander or designated privileging official.

Who Needs to Complete DA Form 5440-31?

  • Chiropractors seeking or renewing privileges in Army MTFs or DoD facilities.
  • Providers transitioning between facilities or requesting expanded privileges.
  • Part of initial credentialing and periodic re-privileging cycles (typically every 2 years, aligned with DoD/DHA policies).

Note: Similar forms exist for other specialties (e.g., DA Form 5440 series), and DoD-wide processes may apply across services.

How to Fill Out and Submit the Form?

  1. Provider Section: Enter name, facility, and code each privilege. Attach justification for modifications. Sign and date.
  2. Supervisor Review: Department chief reviews, codes approvals, and recommends.
  3. Credentials Review: Committee evaluates and forwards for final decision.
  4. Retention: Keep in the provider’s credential file per AR 40-68 and DHA guidelines.

Always use the latest official PDF from Army Publishing Directorate. Electronic signatures or systems may be used in modern MTFs.

Tips for Chiropractors in the Military

  • Base privileges on your CCE-accredited education, residency/fellowship (if any), and documented experience.
  • Stay current with DoD chiropractic integration initiatives and evidence-based practices.
  • Core privileges generally cover spinal manipulation, exams, basic imaging/labs, and modalities. Advanced privileges (e.g., EMG) may require additional documentation.
  • Understand facility limitations — not all MTFs have identical equipment or support.
  • AR 40-68: Clinical Quality Management
  • DHA Procedural Manuals on credentialing and privileging
  • DoD Instruction 6025.13 (Medical Quality Assurance)
  • Air Force or Navy equivalents for joint facilities

Download the Form Here: DA Form 5440-31 Official PDF

For questions about your specific facility’s process, contact your MTF Credentials Office or Medical Staff Services.