DA Form 5754 PDF: Malpractice History Questionnaire – If you’re a healthcare provider—military or civilian—seeking clinical privileges in a U.S. Army medical treatment facility (MTF), DA Form 5754 is a required document in the credentialing process. Also known as the Malpractice History and Clinical Privileges Questionnaire, this form helps document your professional qualifications for staff appointments and clinical privileges.
In this comprehensive guide, we cover everything U.S.-based Army medical professionals need to know: what the form is, who must complete it, how to fill it out correctly, its role under AR 40-68 (Clinical Quality Management), and the official download link. Whether you’re applying for initial privileges, re-entering federal service, or renewing your credentials, this article provides the most current, trusted information directly from Army publications.
What Is DA Form 5754?
DA Form 5754 (April 2009 edition) is the official U.S. Department of the Army form titled Malpractice History and Clinical Privileges Questionnaire. It is used exclusively by the Army Medical Department (AMEDD) to evaluate healthcare providers’ backgrounds before granting or renewing clinical privileges.
- Proponent: Office of The Surgeon General (OTSG)
- For use with: AR 40-68, Clinical Quality Management (26 February 2004, with Rapid Action Revision 22 May 2009)
- Status: Still the current form as of 2026; previous editions (e.g., June 1991 or February 2004) are obsolete.
The form is exempt from discovery under 10 U.S.C. 1102 and includes a Privacy Act statement protecting how your information is used.
Purpose of the Malpractice History and Clinical Privileges Questionnaire
The primary purpose of DA Form 5754 is to:
- Document your professional qualifications as the basis for clinical privileges and staff appointments.
- Support the full credentialing and privileging process in Army MTFs.
- Ensure patient safety by identifying any history of malpractice claims, disciplinary actions, license restrictions, or health issues that could affect your ability to practice.
A completed copy is retained in your provider credentials file. The Army may verify the information with malpractice carriers and previous institutions.
Who Must Complete DA Form 5754?
You are required to complete this form if you are a healthcare provider (military or civilian) in any of these situations:
- Initial entry into Federal Service (e.g., new active-duty physicians, nurses, dentists, or contract providers).
- Re-entry into Federal Service after a break.
- Periodic renewal of clinical privileges (typically every 2 years).
Covered providers include physicians, dentists, nurses, physician assistants, clinical psychologists, pharmacists, and other licensed professionals listed in AR 40-68.
Note: This form applies to U.S. Army facilities nationwide and supports DoD-wide credentialing standards.
Key Sections of DA Form 5754 Explained
The two-page form collects the following information:
- Provider Information – Name, rank/grade, date of birth, specialty/AOC, and medical/dental facility.
- Yes/No Questions (Block 6) – 14 critical questions covering:
- Appearance before medical/regulatory boards for impairment.
- History of substance abuse.
- Suspension/revocation of narcotics registration or licenses.
- Denial, suspension, or restriction of privileges.
- Malpractice claims, settlements, or adjudications.
- Resignation under investigation.
- Insurance cancellations or restrictions.
- Medicare/Medicaid sanctions.
Important: Every question requires a YES or NO answer. Any “YES” must be fully explained in Block 7, referencing the specific question (e.g., “6g”). Include details not covered on previous submissions.
- Health Status (Block 8) – Brief description of your current physical and mental health and ability to perform requested privileges.
- Malpractice Insurance History (Block 9) – List current and (for initial applicants) past 10 years of carriers, addresses, and policy numbers.
- Clinical Privileges History (Block 10) – List hospitals/institutions where you currently hold (or held in the past 10 years for initial applicants) privileges, with dates.
- Certification & Signature – You certify the information is true and authorize the Army to verify it with carriers and institutions.
Step-by-Step: How to Fill Out DA Form 5754?
- Download the official fillable PDF from the U.S. Army Publishing Directorate.
- Use black ink or complete electronically (recommended).
- Answer every question honestly—false information can delay or disqualify your application.
- Provide detailed explanations for any “YES” answers on a separate sheet if needed.
- Attach supporting documents if requested by your credentials committee.
- Sign and date the certification block.
- Submit to your local Medical Treatment Facility Credentials Office.
Pro Tip: Initial applicants should gather malpractice carrier contact information early—carriers often send verification directly to the Army.
Why DA Form 5754 Matters in the Army Credentialing Process?
Under AR 40-68, the Army maintains rigorous standards for clinical quality. DA Form 5754 is a key component alongside:
- DA Form 5440 series (Delineation of Clinical Privileges)
- Curriculum vitae
- License verifications
- National Practitioner Data Bank (NPDB) queries
Accurate completion protects patients, ensures compliance with federal law (including 10 U.S.C. 1094 for unrestricted licenses), and speeds up your privileging timeline.
Official Download: DA Form 5754 PDF
Direct link to the current fillable PDF (April 2009 edition):
Download DA Form 5754 Here
Always use the official Army Publishing Directorate (armypubs.army.mil) source to ensure you have the latest authorized version.
Frequently Asked Questions (FAQs)
Q: Is DA Form 5754 still required in 2026?
Yes. No superseding form has been issued, and it remains referenced in current Army guidance.
Q: Do contractors need to complete it?
Yes—civilian contract providers working in Army MTFs must complete it for initial and renewal privileging.
Q: What if I have a “YES” answer?
Provide a clear, factual explanation. The credentials committee will review it; full disclosure is required.
Q: How long does it take to process?
Processing varies by facility but starts once your full credentials packet (including this form) is received.
Q: Where do I submit the form?
To the Credentials Office at the MTF where you are applying for privileges.
Related Resources for Army Medical Providers
- AR 40-68: Clinical Quality Management (full regulation)
- DA Form 5440 series for privilege delineation
- U.S. Army Medical Command (MEDCOM) credentialing guidance
- National Practitioner Data Bank (NPDB) self-query instructions
Need help with DA Form 5754? Contact your local MTF Credentials Administrator or the Office of The Surgeon General for official guidance. Accurate completion helps ensure smooth privileging and supports high-quality care for our Soldiers and beneficiaries across the United States.