DA FORM 4691-1 Fillable – Army Pubs 4691-1 PDF

DAFORMFILLABLE.COM | DA FORM 4691-1 Fillable – Army Pubs 4691-1 PDFDA FORM 4691-1, officially titled the Application For Renewal Of Clinical Privileges And Staff Appointment, is a crucial document used within the U.S. Army medical system. This form, with the publication number DA FORM 4691-1, was first introduced on February 1, 2004. It serves to renew clinical privileges and staff appointments for healthcare professionals, ensuring that they meet the necessary qualifications and standards to provide medical care within military facilities.

DA FORM 4691-1 – Application For Renewal Of Clinical Privileges And Staff Appointment

Form Number DA Form 4691-1
Form Title Application For Renewal Of Clinical Privileges And Staff Appointment
Form Date 02/01/2004
Form Proponent TSG

Understanding DA FORM 4691-1

Purpose and Importance

The DA FORM 4691-1 is designed to streamline the process of renewing clinical privileges for medical staff. This form ensures that all healthcare professionals have the required competencies and meet the standards set by military regulations. By regularly updating clinical privileges, the Army maintains a high level of medical care and patient safety.

Form Proponent and Status

The form is sponsored by the TSG (The Surgeon General) and is currently in active status. This means it is actively used in the field and remains a critical component of the military medical administrative process.

Prescribing Directive

The use and guidelines for DA FORM 4691-1 are outlined in AR 40-68, which governs the standards of medical care and the credentialing of healthcare professionals within the Army. This regulation ensures that all procedures related to the renewal of clinical privileges are standardized and adhere to strict quality control measures.

Key Features of DA FORM 4691-1

Electronic Media and Privacy

The form is produced exclusively in electronic media. This allows for easier distribution and accessibility, ensuring that all relevant parties can obtain and submit the form efficiently. Moreover, it requires a Privacy Act Statement as per AR 340-21, ensuring that all personal information collected is handled in compliance with privacy regulations.

Security and Distribution

The DA FORM 4691-1 is classified as UNCLASSIFIED, meaning it does not contain sensitive information that could compromise national security. The distribution restriction code is A, which indicates that the form is approved for public release and its distribution is unlimited. This broad accessibility underscores the form’s role in maintaining operational transparency and efficiency within the Army’s medical services.

Completing the DA FORM 4691-1

Information Required

When filling out the DA FORM 4691-1, healthcare professionals must provide detailed information about their credentials, including their qualifications, past clinical privileges, and any additional training or certifications they have completed since their last appointment. This information helps verify that they continue to meet the necessary standards to practice within the military healthcare system.

Submission Process

Upon completion, the form must be submitted to the appropriate reviewing authority, typically within the medical command structure. The submission process ensures that each application is thoroughly reviewed and that the healthcare professional is either reappointed with the necessary privileges or provided with feedback on any additional requirements they must meet.

Importance of Regular Renewal

Maintaining Standards

Regular renewal of clinical privileges is essential for maintaining high standards of medical care within the Army. It ensures that all healthcare providers are up-to-date with the latest medical practices and continue to meet the rigorous standards set by military regulations.

Enhancing Patient Safety

By regularly renewing clinical privileges, the Army can better ensure patient safety. Updated credentials and ongoing professional development help reduce the risk of medical errors and improve overall healthcare outcomes for service members.


DA FORM 4691-1 plays a vital role in the U.S. Army’s healthcare system by ensuring that all medical professionals maintain the necessary credentials and standards to provide high-quality care. The form’s structured approach to renewing clinical privileges helps maintain operational efficiency and enhances patient safety. Adhering to the guidelines outlined in AR 40-68 and ensuring the form is completed accurately and submitted timely are essential steps in this ongoing process.

For more detailed information or to access the form, individuals can refer to the Army’s electronic media resources or consult their medical command for further guidance.

DA FORM 4691-1 Fillable – Army Pubs 4691-1 PDF DOWNLOAD

Download PDF
DA FORM 4691-1 - Application For Renewal Of Clinical Privileges And Staff Appointment_page-0002 DA FORM 4691-1 - Application For Renewal Of Clinical Privileges And Staff Appointment_page-0001