Get U.s. Dod Form Dod-da-5440-16 - Usa-federal-forms.com

This guide provides a step-by-step approach to filling out the U.S. DOD Form Dod-da-5440-16, which is used for delineation of clinical privileges for nurse practitioners. Whether you are a provider or a supervisor, this document is essential for recognizing clinical competencies and authorizations.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the name of the provider in the 'NAME OF PROVIDER' field, including the last name, first name, and middle initial.
3. Next, input the rank or grade of the provider in the 'RANK/GRADE' field.
4. Fill in the facility name in the 'FACILITY' field to identify where the privileges will be applied.
5. In Section I, enter the appropriate provider codes in the 'REQUESTED' column, crossing out and initialing any privileges not applicable.
6. If you are the provider, sign at the end of Section I to validate your requested privileges.
7. If you are the supervisor, review the provider's requested privileges and enter the appropriate approval codes in the 'APPROVED' column.
8. Ensure that the supervisor provides their signature in Section II, indicating the overall recommendation.
9. In Section III, the credentials committee must indicate the recommendation status and provide the committee chairperson’s signature.
10. After filling out all sections, you can save your changes, download, print, or share the completed form as needed.

Complete your documents online efficiently and accurately!