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Cy is OTSG. 2. RANK/GRADE 3. FACILITY INSTRUCTIONS: PROVIDER: Enter the appropriate provider code in the column marked "REQUESTED". Each category and/or individual privilege listed must be coded. For procedures listed, line through and initial any criteria/applications that do not apply. Your signature is required at the end of Section I. Once approved, any revisions or corrections to this list of privileges will require you to submit a new DA Form 5440. SUPERVISOR: Review each category and/or.

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