DAFORMFILLABLE.COM | DA FORM 4691 Fillable – Army Pubs 4691 PDF – DA FORM 4691, also known as the Initial Application For Clinical Privileges And Staff Appointment, is a crucial document used within the military healthcare system. This form is essential for healthcare professionals seeking to obtain clinical privileges and staff appointments within military medical facilities. Below is an in-depth look into this form, its purpose, and its application process.
DA FORM 4691 – Initial Application For Clinical Privileges And Staff Appointment
| Form Number | DA Form 4691 |
| Form Title | Initial Application For Clinical Privileges And Staff Appointment |
| Form Date | 02/01/2004 |
| Form Proponent | TSG |
Overview of DA FORM 4691
Publication Number: DA FORM 4691
Publication Date: February 1, 2004
Publication Title: Initial Application For Clinical Privileges And Staff Appointment
Proponent: The Surgeon General (TSG)
Status: Active
Purpose of DA FORM 4691
DA FORM 4691 serves as the initial application for healthcare professionals who wish to be granted clinical privileges and a staff appointment at military medical facilities. This form is designed to ensure that applicants meet all necessary qualifications and standards required to provide healthcare services within the military context.
Application Process
Submission Requirements
To apply for clinical privileges and a staff appointment, applicants must complete DA FORM 4691 in accordance with the guidelines outlined in AR 40-68. This regulation prescribes the standards and procedures for obtaining and maintaining clinical privileges within the Army Medical Department.
Privacy Act Statement
Applicants must be aware that DA FORM 4691 requires a Privacy Act Statement as stipulated in AR 340-21. This statement ensures that the applicant’s personal information is protected and used only for the intended purposes of the application process.
Electronic Submission
This form is only produced in electronic media, simplifying the submission process and ensuring that applications can be processed efficiently. The digital format also helps maintain accurate records and facilitates quicker review and approval.
Important Considerations
Security Classification and Distribution
DA FORM 4691 is classified as UNCLASSIFIED, meaning it does not contain sensitive information that would warrant a higher security classification. The form carries a Distribution Restriction Code A, indicating that it is approved for public release and that its distribution is unlimited. This ensures that the form is accessible to all potential applicants without restrictions.
Publication Details
- Publication IDN: 990001
- Publication PIN: 033640
Changes and Updates
Currently, there are no known changes or updates to DA FORM 4691. It remains an active and essential document for the Army Medical Department’s credentialing process.
Conclusion
DA FORM 4691 is a vital tool for healthcare professionals aiming to secure clinical privileges and staff appointments within military medical facilities. By understanding the form’s purpose, application process, and relevant guidelines, applicants can ensure they meet all necessary requirements for a successful application. Utilizing this form correctly is the first step towards contributing valuable healthcare services within the military system.
For more detailed information, applicants should refer to AR 40-68 and ensure that all personal data is accurately and securely submitted as per the Privacy Act Statement.
DA FORM 4691 Fillable – Army Pubs 4691 PDF DOWNLOAD
