AF_Form_1540_final-2004 1 .rtf

APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT

AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102.

PRINCIPAL PURPOSE: To evaluate professional criteria for medical staff membership and clinical privileges; designed to help establish an applicant’s background, current competence, and physical and mental ability to discharge patient care responsibilities. This evaluation is essential to establishing and maintaining a qualified, competent medical staff.

ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force.

DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges.

APPLICANT COMPLETES SECTIONS I THROUGH X

I. IDENTIFICATION (All date entries must be entered as MM/DD/YYYY) NAME (Last, First, Middle Name) ALIAS (i.e., Maiden)