DA Form 5440-52: Critical Care Medicine Privileges Guide

DA Form 5440-52: Critical Care Medicine Privileges Guide – DA Form 5440-52: Delineation of Clinical Privileges – Critical Care Medicine is an official U.S. Army form used to request, review, and approve specific clinical privileges for healthcare providers practicing in critical care settings within military treatment facilities (MTFs).

This form ensures that physicians and other qualified providers demonstrate the necessary training, experience, and competency to manage critically ill patients, aligning with Army Regulation (AR) 40-68, Clinical Quality Management.

What Is DA Form 5440-52?

DA Form 5440-52, titled Delineation of Clinical Privileges – Critical Care Medicine, is part of the Army’s credentialing and privileging process. It is used in conjunction with DA Form 5440-3 (Internal Medicine) or DA Form 5440-13 (General Surgery).

Key purpose: It allows providers to request privileges for advanced procedures and patient management in intensive care units (ICUs), while supervisors and credentials committees evaluate and approve based on documented competence.

The form was last issued in FEB 2004 and remains in active use across the Military Health System (MHS). Recent MHS updates (as of late 2025) streamline privileging transfers between facilities, reducing administrative burdens for providers.

Who Uses This Form?

  • Providers: Board-eligible or board-certified physicians in critical care medicine (often with backgrounds in internal medicine, surgery, anesthesiology, or emergency medicine), typically assigned to Army MTFs.
  • Supervisors: Department chiefs or service leaders who review requests.
  • Credentials Committees: Final recommendation and approval authority at the facility level.
  • Target audience: U.S. Army Medical Corps officers, civilian providers in military facilities, and other qualified MHS personnel.

It supports high standards of care for active duty service members, families, and retirees in military hospitals.

Key Sections of DA Form 5440-52

Section I – Clinical Privileges (Provider Requests):
Providers use a coding system (1-5) to indicate their request level for each privilege:

  • 1: Fully competent
  • 2: Modification requested (with justification)
  • 3: Supervision requested
  • 4: Not requested (lack of expertise)
  • 5: Not requested (lack of facility support/mission)

Core and Specific Privileges (examples from the form):

  • Management of pediatric intensive care disorders
  • Treatment of respiratory failure
  • Thoracentesis, paracentesis, pericardiocentesis
  • Tube thoracostomy, flexible bronchoscopy
  • Intubation (oral/nasotracheal), percutaneous tracheostomy
  • Ventilator management (including high-frequency)
  • Central venous line placement, Swan-Ganz catheterization, arterial line placement
  • Intracranial pressure monitoring
  • Lumbar puncture, peritoneal dialysis procedures
  • Cardioversion/defibrillation, transvenous pacemaker insertion
  • Moderate sedation, respiratory therapy supervision
  • And others (with space to specify)

Section II – Supervisor’s Recommendation
Section III – Credentials Committee/Function Recommendation (Approval, modifications, or disapproval).

Providers must sign and date; revisions require a new form.

How to Complete and Submit DA Form 5440-52?

  1. Download the official PDF: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5440_52.pdf.
  2. Fill in provider details (name, rank, facility).
  3. Code each privilege in the “Requested” column.
  4. Provide justifications for modifications or supervision.
  5. Obtain supervisor review and codes in the “Approved” column.
  6. Route through department chief and credentials committee for final approval.
  7. Retain records per AR 40-68 and MHS policies.

Tip for providers: Base requests on your training logs, case volumes, board certification, and recent performance evaluations. Recent MHS reforms emphasize portable privileges across facilities.

Why Proper Privileging Matters in Critical Care Medicine?

Critical care involves life-saving interventions for patients with multi-organ failure, post-surgical complications, trauma, and severe infections. Accurate delineation of privileges:

  • Protects patient safety.
  • Ensures compliance with Joint Commission standards and DoD/MHS requirements.
  • Supports operational readiness in garrison and deployed settings.
  • Facilitates seamless care transitions under the unified MHS structure.

Similar forms exist for other specialties, but DA Form 5440-52 specifically addresses ICU-level expertise beyond core internal medicine or surgery privileges.

  • AR 40-68: Clinical Quality Management (governs the entire process).
  • Military Health System privileging updates for streamlined transfers.
  • Other DA Forms 5440 series for related specialties.

Download DA Form 5440-52 Here: Official Army Publishing Directorate Link

For questions about completing this form or credentialing in the U.S. Army or MHS, consult your facility’s credentials office or Medical Staff Services. Always refer to the most current guidance from the Defense Health Agency (DHA) and your local MTF policies, as processes continue to evolve for better efficiency.