Get U.s. Dod Form Dod-da-5440-28. Free Download

This guide provides clear instructions on how to correctly complete the U.S. DOD Form Dod-da-5440-28, which is used for delineating clinical privileges for social work providers. Following this comprehensive guide will help ensure a smooth filing process.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. In Section I, enter your name as the provider in the format of last name, first name, and middle initial in the designated space. Additionally, input your rank or grade and the facility where you practice.
3. For the provider codes, refer to the list provided and enter the appropriate code for the privileges you are requesting in the 'REQUESTED' column. Make sure to cross out and initial any criteria or applications that do not apply to you.
4. Sign your name at the end of Section I to certify the information provided is accurate and complete.
5. In Section II, your supervisor must review the privileges you requested. They will enter the corresponding approval code in the 'APPROVED' column, providing their overall recommendation.
6. Section II also requires your supervisor's signature and the date, confirming their approval or modifications to your requests.
7. If applicable, Section III needs to be filled out by the Credentials Committee/Function. They will review and sign off on the approval request, noting any modifications as necessary.
8. Once you have filled out all relevant sections, save your changes. You may then choose to download, print, or share the completed form as needed.

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