Renewal staff 2026

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4.8 out of 5

42 votes

The U.S. DOD Form dod-da-4691-1 is an application for the renewal of clinical privileges and staff appointment for military and civilian healthcare providers. It requires personal identification, professional education details, licensure information, and a request for specific clinical privileges. The form aims to document qualifications for credentialing purposes and must be completed by providers seeking reappointment after a lapse in privileges exceeding 180 days.

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Click ‘Get Form’ to open the renewal staff document in the editor.
Begin with Section I - Identification. Fill in your name, rank/grade, SSN, date of birth, and medical/dental facility details accurately.
Proceed to Section II - Professional Education. List your educational data including residency training and any certifications since your last application.
In Section III - Licensure/Certification/Registration, provide details about your state licensing agency, DEA registration, and any relevant certifications.
Move to Section IV - Clinical Privileges Requested. Indicate the type of privileges you are applying for and confirm your competency.
Finally, complete Section V - Comments if necessary. Ensure all information is accurate before signing and dating the form in Section VI.

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Versions	Form popularity	Fillable & printable
2004	4.8 Satisfied (42 Votes)

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