Get U.s. Dod Form Dod-da-5440-14. Free Download

The U.S. DOD Form Dod-da-5440-14 is essential for delineating clinical privileges for nurse anesthetists. This guide provides a clear and supportive approach to effectively fill out this form, ensuring all necessary information is accurately documented.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to access the U.S. DOD Form Dod-da-5440-14. This will allow you to download and open the form for further completion.
2. In Section I, enter your name in the 'NAME OF PROVIDER' field. Make sure to include your last name, first name, and middle initial.
3. Fill in your rank or grade in the appropriate field directly under your name.
4. Provide the facility name where you practice in the 'FACILITY' section.
5. Complete the 'REQUESTED' column by entering the appropriate provider codes corresponding to each privilege. Ensure to line through and initial any privileges that do not apply to you.
6. Once you have filled out your requested privileges, sign at the end of Section I. This signature indicates that you are confirming the information provided.
7. In Section II, if you are a supervisor, review the coded privileges and enter the corresponding approval codes in the 'APPROVED' column. You will also need to add the necessary comments and sign this section to provided recommendations.
8. For Section III, if applicable, you can add comments related to the credentials committee's recommendations along with the approval codes. Ensure all relevant signatures and dates are included.
9. After completing all sections, you can save your changes, and choose to download the filled form or print it directly for submission.

Complete your U.S. DOD Form Dod-da-5440-14 online today for a seamless experience.