DA Form 5440-55: Orthopaedics Clinical Privileges Guide – DA Form 5440-55: Delineation of Clinical Privileges – Orthopaedics is a key U.S. Army document used in the military healthcare system to define and grant specific clinical privileges to orthopedic surgeons and qualified providers.
This form ensures that orthopedic care in Army Medical Treatment Facilities (MTFs) meets high standards of competency, patient safety, and regulatory compliance under AR 40-68, Clinical Quality Management.
What Is DA Form 5440-55?
DA Form 5440-55 (February 2004 edition) is titled “Delineation of Clinical Privileges – Orthopaedics.” It belongs to the DA Form 5440 series, which standardizes the privileging process across Army medicine for various specialties.
Purpose: It allows orthopedic providers to request specific procedures and levels of care based on their training, experience, and demonstrated competence. Supervisors and credentials committees then review and approve (or modify) these requests.
The form supports the Army’s credentialing system, which verifies that providers can safely perform orthopedic services for service members, families, and other beneficiaries.
Download the Official Form:
DA Form 5440-55 PDF (U.S. Army Publishing Directorate).
Who Uses DA Form 5440-55?
- Orthopedic surgeons (board-eligible or certified) in Army hospitals, clinics, and deployed settings.
- Physician assistants or other providers with orthopedic specialty training (often in conjunction with related forms like DA Form 5440-18).
- Military Treatment Facilities (MTFs) for initial appointment, re-privileging (typically every 2 years), and modifications.
It aligns with broader Department of Defense and Army policies on clinical quality, patient safety, and provider competency.
Key Sections and Privileges on DA Form 5440-55
Providers use a coding system (1 = fully competent; 2 = modification requested; etc.) to indicate requested and approved privileges. The form lists core orthopedic procedures, including:
- Amputations (major)
- Arthrocentesis, diagnostic and therapeutic
- Arthroscopy (diagnostic and surgical)
- Arthrodesis, arthroplasty, and arthrotomy
- Bone graft procedures and bone/muscle transpositions
- Excision of tumors, bursae, herniated discs, etc.
- Fracture and dislocation management (open/closed reduction, internal/external fixation, skeletal traction)
- Spine procedures: Laminectomy (cervical, thoracic, lumbar), fusions, discectomy, scoliosis/kyphosis correction
- Joint and prosthetic replacements
- Tendon, ligament, and nerve repairs/grafts
- Soft tissue procedures: Flaps, grafts, releases
- Other: Osteomyelitis drainage, manipulation of deformities, regional anesthesia blocks, myelography, etc.
Privileges are often categorized by complexity (e.g., core/general vs. advanced/subspecialty) and tied to the provider’s documented training, case volume, and ongoing performance.
Note: The form is used with supporting documentation such as training certificates, case logs, proctoring evaluations, and performance reviews.
The Privileging Process in Army Medicine
- Provider Request — Completes Section I, requesting privileges with supporting evidence.
- Supervisor Review — Department chief or supervisor recommends approval/modification in Section II.
- Credentials Committee — Reviews and recommends in Section III.
- Commander Approval — The MTF commander has final authority to grant privileges.
- Ongoing Monitoring — Privileges are reviewed periodically with proctoring, quality data, and peer review per AR 40-68.
This process protects patients and ensures providers practice within their scope of competence.
Why It Matters for Orthopedic Care in the Military?
Orthopedic surgeons in the Army treat a wide range of musculoskeletal conditions — from combat trauma and sports injuries to degenerative diseases and reconstructive needs. Proper delineation of privileges:
- Maintains high-quality surgical outcomes.
- Supports readiness by ensuring deployable surgeons have verified skills.
- Complies with accreditation standards (e.g., The Joint Commission) and federal regulations.
Similar forms exist across military services and civilian hospitals for consistency in granting orthopedic privileges.
Tips for Completing or Understanding the Form
- Be accurate and attach justifications for any modifications.
- Maintain current logs of procedures performed.
- Stay updated on AR 40-68 and facility-specific privileging policies.
- For re-privileging, demonstrate ongoing competence through volume, outcomes, and continuing education.
For Official Use: Always refer to the latest guidance from the Office of The Surgeon General (OTSG), your local Credentials Office, or armypubs.army.mil. Forms and policies can be updated; verify the current version.