DA Form 5440-6: Army Optometry Clinical Privileges Guide – If you are a U.S. Army optometrist, military healthcare provider, or administrator involved in credentialing and privileging within Army Medical Department (AMEDD) facilities, understanding DA Form 5440-6 is essential. This official form standardizes the process for requesting, reviewing, and granting clinical privileges in optometry services across Army healthcare settings.
What Is DA Form 5440-6?
DA Form 5440-6, titled Delineation of Clinical Privileges – Optometry Service, is a standardized U.S. Army form used to document and authorize the specific clinical procedures and responsibilities an optometrist may perform. It falls under Army Regulation (AR) 40-68, Clinical Quality Management (with Rapid Action Revision from 2009).
The form ensures that optometrists practice only within their demonstrated competence, training, experience, and facility capabilities while maintaining high standards of patient safety and quality care in military treatment facilities (MTFs).
Download the official form here: DA Form 5440-6 PDF.
Purpose of the Form
The primary goal is to delineate (clearly define) clinical privileges for optometry providers. It covers:
- Diagnosis and management of various ocular conditions.
- Specific procedures optometrists can perform.
- Prescribing authority for medications and devices.
This supports credentialing, privileging, and quality management processes required for all healthcare providers in the Army. Privileges are typically reviewed and renewed periodically, often tied to performance evaluations and continuing education.
Who Uses DA Form 5440-6?
- Providers: Army optometrists (active duty, reserve, or civilian) requesting privileges.
- Supervisors: Service chiefs or designated reviewers who recommend approval levels.
- Credentials Committees: For final recommendations and commander approval.
- Facilities: Army hospitals, clinics, and medical centers worldwide.
It aligns with broader Department of Defense and Army policies on provider competency.
How to Complete DA Form 5440-6? Step-by-Step
The form uses a coding system for both the provider (REQUESTED) and supervisor (APPROVED):
Provider Codes (what you request):
- 1 — Fully competent to perform (justification attached if needed).
- 2 — Modification requested.
- 3 — Supervision requested.
- 4 — Not requested (lack of expertise).
- 5 — Not requested (lack of facility support/mission).
Supervisor Codes mirror these for approval decisions.
Key Sections
Section I – Clinical Privileges (Core of the form):
Diagnosis and Management of:
- Refractive error problems
- Binocularity problems
- Accommodative problems
- Low-vision problems
- Developmental and perceptual problems
- Contact lens problems
- Diseases and disorders of the visual system, eye, and associated structures (includes ordering lab/diagnostic imaging tests, prescribing topical/oral medications for allergies, infections, inflammation, glaucoma, pain, and refills of expired prescriptions).
Procedures (extensive list including):
- Comprehensive eye exams and evaluations (new/established patients).
- Determination of refractive state.
- Gonioscopy, sensorimotor exams, visual field testing.
- Ophthalmoscopy, tonometry, imaging (scanning computerized, ocular photography, ultrasound).
- Contact lens fitting (including for disease/aphakia).
- Low vision aid evaluation.
- Minor procedures: Foreign body removal (cornea/conjunctiva), corneal scraping/epithelium removal, lacrimal punctum procedures, pachymetry, electrodiagnostic testing, trichiasis correction (epilation).
Providers must initial/line through non-applicable items. A signature and date are required.
Subsequent Sections cover supervisor recommendations, credentials committee input, and final approvals with comments for modifications or disapprovals.
Important: Once approved, any changes require a new DA Form 5440-6 submission.
Why Clinical Privileges Matter in Army Optometry?
Army optometrists play a critical role in Soldier readiness—providing primary eye care, managing ocular disease, supporting deployments, and ensuring visual fitness. Proper privileging:
- Ensures compliance with AR 40-68 standards.
- Protects patients and providers.
- Facilitates scope-of-practice alignment with training (e.g., Doctor of Optometry degree, residency, board certification, and state licensure).
- Supports career progression and assignments in diverse settings, from garrison clinics to forward-deployed environments.
Similar processes exist in other branches and civilian/VA settings, but Army-specific forms like this maintain uniformity.
Tips for Successful Privileging
- Prepare Documentation: Include current license, certifications (e.g., NBEO), training logs, case logs, and continuing education.
- Be Realistic: Request privileges matching your experience and facility resources.
- Justify Requests: Attach supporting evidence for Code 1 or modifications.
- Stay Current: Monitor Army Publishing Directorate (armypubs.army.mil) for form updates and AR 40-68 guidance.
- Renew Timely: Privileges are time-limited; track expiration dates.
For questions, consult your local credentials office, Optometry Service Chief, or AMEDD resources.
DA Form 5440-6 is a foundational tool for professional accountability and quality eye care delivery in the U.S. Army. By clearly defining optometric privileges, it helps maintain readiness while upholding the highest standards of military healthcare.