AF Form 22: Clinical Privileges Evaluation Summary Guide

AF Form 22: Clinical Privileges Evaluation Summary Guide – AF Form 22, officially titled Clinical Privileges Evaluation Summary, is a key document in the United States Air Force Medical Service (AFMS). It supports the credentialing and privileging process for healthcare providers, ensuring that physicians, dentists, nurses, and other professionals deliver safe, high-quality care within their demonstrated competencies.

Military treatment facilities (MTFs) and Air Force medical units rely on this form to document performance evaluations tied to clinical privileges. It helps maintain standards aligned with Department of Defense (DoD) and Air Force policies for patient safety and quality management.

What Is AF Form 22 and Its Purpose?

The AF Form 22 provides a structured summary of a provider’s clinical performance, competence, and suitability for requested or existing privileges. Clinical privileges define the specific procedures, treatments, and patient care activities a provider may perform independently at an Air Force medical facility.

Primary purposes include:

  • Documenting supervisor or peer evaluations of a provider’s experience, current competence, and ability to perform requested privileges.
  • Supporting initial granting, renewal, modification, or revocation of clinical privileges.
  • Contributing to the Provider Activity File (PAF) and overall credentialing process.
  • Ensuring compliance with quality assurance, risk management, and performance improvement requirements in the AFMS.

The form is referenced in AFI 44-119, Medical Quality Operations (and its updates), which outlines credentialing, privileging, and peer review processes. It works alongside other documents like AF Forms 1562, DHA privilege lists, and the Centralized Credentials Quality Assurance System (CCQAS).

Note: The official form is available as a PDF download from the Air Force e-Publishing site: AF Form 22 PDF. Always use the most current version from official .mil sources for official submissions.

Who Uses AF Form 22?

  • Healthcare Providers: Physicians, physician assistants, nurse practitioners, dentists, clinical psychologists, and other privileged professionals in the AFMS.
  • Clinical Supervisors: Department chiefs, medical directors, or designated evaluators who complete the evaluation.
  • Credentials Committees: Executive Committee of the Medical Staff (ECOMS) and Medical Treatment Facility Commanders (MTF/CC) use it during privileging decisions.
  • Air Reserve Component (ARC) units: With some variations in process.

It applies to both active duty and certain civilian/contractor providers working in Air Force facilities. The form emphasizes evaluation based on training, experience, demonstrated performance, and health status.

Key Sections of AF Form 22

Although the exact layout can vary slightly by revision (the base edition dates to 1989 with later updates), typical blocks include:

  1. Provider Information: Name of provider, Social Security Number (or equivalent), rank/grade, and duty location.
  2. Evaluation Period: Dates covered by the summary.
  3. Clinical Privileges Requested or Currently Held: Summary of specific privileges under review.
  4. Performance Evaluation: Comments on competence, quality of care, patient outcomes, adherence to standards, and any notable incidents or achievements. Additional pages may be attached for detailed explanations.
  5. Recommendations: Supervisor’s recommendation regarding continuation, modification, or restriction of privileges.
  6. Signatures: Evaluator (clinical supervisor) and reviewer signatures with dates.

The form stresses using additional paper or attachments when necessary to fully explain comments. It focuses on objective assessment of current competence rather than just volume of procedures.

Samples and detailed guidance appear in attachments to AFI 44-119.

How AF Form 22 Fits into the Broader Privileging Process?

Clinical privileging in the Air Force follows a rigorous, multi-step process governed primarily by AFI 44-119 and DoD/Defense Health Agency (DHA) policies (such as DHA PM 6025.13, Volume 4 – Credentialing & Privileging):

  • Initial Application: Providers submit privilege requests using specialty-specific DHA or triservice master privilege lists.
  • Credentials Review: Verification of education, training, licensure, board certification, and prior performance.
  • Evaluation: Use of AF Form 22 (and related performance reports) during focused professional practice evaluation (FPPE) or ongoing professional practice evaluation (OPPE).
  • Committee Review: Credentials Function and ECOMS review documentation before recommending to the MTF Commander.
  • Granting/Renewal: Privileges are typically granted for a set period (often 2 years) and require periodic re-evaluation.
  • Peer Review and Quality Data: Input from case reviews, moderate sedation logs, trauma experience, or other metrics may feed into the AF Form 22.

For providers at geographically separated units or in deployment settings, additional processes ensure continuity.

Tips for Completing and Using AF Form 22 Effectively

  • Be Objective and Specific: Base comments on observable performance, patient outcomes, and compliance with evidence-based standards. Avoid vague language.
  • Use Attachments: Provide supporting data (e.g., case logs, quality metrics) when explaining strengths, concerns, or limitations.
  • Timeliness: Complete evaluations as part of periodic privileging cycles or when performance issues arise.
  • Compliance: Follow current AFI 44-119, local MTF bylaws, and DHA guidance. Failure to provide required information can lead to limitations on privileges.
  • Digital/Modern Systems: While the paper form remains in use, many elements integrate with CCQAS/Joint systems for streamlined tracking.

Providers and supervisors should consult their local Credentials Manager or SGH (Chief of Medical Staff) for facility-specific instructions.

Why AF Form 22 Matters for Patient Safety and Military Readiness?

Accurate completion of the AF Form 22 helps ensure that only qualified providers exercise clinical privileges. This directly supports:

  • High standards of care for active duty members, families, and retirees.
  • Risk management and reduction of adverse events.
  • Compliance with The Joint Commission (TJC) standards (where applicable) and DoD quality programs.
  • Medical readiness for deployment and operational missions.

In cases involving moderate sedation, trauma skills sustainment, or specialty procedures, the form often documents specific competencies and case volumes.

Download the Official AF Form 22

For related forms and privilege lists, visit the Air Force Medical Service Credentials Verification Office pages or your MTF’s internal resources.

Disclaimer: This article provides general information based on publicly available Air Force publications and references. It is not a substitute for official guidance, local policy, or legal advice. Providers and supervisors must refer to current AFIs, DHA instructions, and consult their credentials office for official processes. Policies can be updated; check e-Publishing.af.mil for the most recent versions.

If you are an Air Force medical professional preparing for privileging, contact your facility’s Credentials Function or SGH for tailored support. Proper use of AF Form 22 contributes to excellence in Air Force healthcare delivery.