DA Form 5440-49: Plastic Surgery Clinical Privileges

DA Form 5440-49: Plastic Surgery Clinical Privileges – DA Form 5440-49: Delineation of Clinical Privileges – Plastic Surgery is a key U.S. Army medical form used to request, review, and grant specific clinical privileges to qualified plastic surgeons in military treatment facilities (MTFs).

Military healthcare providers, particularly board-eligible or board-certified plastic surgeons serving in the Army, use this form as part of the credentialing process under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent.

What Is DA Form 5440-49?

This two-page form standardizes the delineation of privileges for plastic surgery procedures. It ensures that providers demonstrate competence in areas matching their training, experience, and facility capabilities. Plastic surgery in this context focuses on restoring form and function to the integumentary (skin) and musculoskeletal systems using specialized techniques, rather than being limited to a specific anatomical region.

Key Details:

  • Date of Form: February 2004 (current official version available via Army Publishing Directorate).
  • Usage: Must be used in conjunction with DA Form 5440-13 (Delineation of Clinical Privileges – General Surgery).
  • Provider Codes (Requested column): 1 = Fully competent; 2 = Modification requested; 3 = Supervision requested; 4 = Not requested (lack of expertise); 5 = Not requested (lack of facility/mission support).
  • Supervisor Codes (Approved column): Similar scale for recommendations to the commander/approval authority.

Download the Official Form Here: DA Form 5440-49 PDF (Direct from Army Publishing Directorate).

Purpose and Process for Army Plastic Surgeons

The form supports the Army’s credentialing system to maintain high standards of care in military hospitals and clinics. Providers list requested privileges; supervisors review and recommend; and a credentials committee provides final input. Revisions require a new form submission.

This process aligns with broader Department of Defense and Army policies on clinical quality, ensuring patient safety for both reconstructive and certain aesthetic procedures performed by privileged providers.

Core Clinical Privileges Outlined in DA Form 5440-49

The form covers a comprehensive range of plastic surgery competencies. Providers must code each category:

  • Wounds and Wound Healing: Difficult wounds, radiation/thermal/cold injuries, infections.
  • Tissue Transplantation: Grafts (skin, fat, muscle, bone, cartilage, hair) and flaps.
  • Microvascular Surgery.
  • Head and Neck: Facial fractures/trauma, craniofacial reconstruction, cleft lip/palate, tumors, facial palsy, orbital procedures.
  • Hand: Acute injuries, replantation, reconstruction, tumors, entrapment syndromes.
  • Extremities and Trunk: Reconstructions, breast/chest/abdominal wall procedures, pressure ulcers.
  • Genitourinary: Hypospadias, genital reconstruction.
  • Skin: Tumor excision, scar revision, keloids, tattoos, etc.
  • Aesthetic Surgery: Mammoplasty (augmentation/reduction), rhinoplasty, rhytidectomy (facelift), blepharoplasty, abdominoplasty, body contouring, chemical peels, dermabrasion, etc.
  • Suction-Assisted Lipectomy (Liposuction).
  • Oculoplastic Procedures: Eyelid tumors, reconstructions.
  • Injections: Steroids, Botox, soft tissue fillers.
  • Moderate Sedation Administration.

Laser Privileges (separate section requiring additional training/documentation):

  • Tunable CO2, Argon, Nd:YAG, Dye lasers for tattoo removal, skin tumors, resurfacing, debridement, reduction mammoplasty, etc.

The list is neither fully inclusive nor exclusive—additional privileges may apply based on training.

Who Needs This Form?

  • Active Duty Army plastic surgeons (e.g., MOS 61L).
  • Civilian providers or contractors in Army MTFs seeking privileges.
  • Residents/fellows in approved training programs (with supervision requirements).

Board certification by the American Board of Plastic Surgery (ABPS) or equivalent strongly supports full privileges.

  • Cosmetic vs. Reconstructive: The military health system prioritizes reconstructive procedures. Cosmetic/elective surgeries follow strict guidelines, often limited to training programs or specific privileged specialists. TRICARE generally does not cover complications from unauthorized civilian cosmetic procedures.
  • Qualifications: Providers typically need residency training, board eligibility/certification, and documented experience. Privileges are facility-specific and reviewed periodically.
  • Broader Military Context: Similar forms exist for other specialties. This supports readiness, graduate medical education, and quality care for service members, families, and retirees.

How to Complete and Submit DA Form 5440-49?

  1. Provider completes Section I (requests).
  2. Supervisor reviews and recommends (Section II).
  3. Credentials Committee/Function reviews (Section III).
  4. Commander approves as the final authority.
  5. Maintain supporting documentation (training logs, case volumes, laser certifications).

For the most current guidance, consult your local Medical Treatment Facility Credentials Office or AR 40-68.

Why This Matters for U.S. Army Healthcare?

Proper privilege delineation protects patients, supports provider competency, and ensures military plastic surgeons can deliver life-changing reconstructive care—from trauma reconstruction to complex wound management—while maintaining readiness.

Official Download: DA Form 5440-49