AF Form 2817-1: Clinical Privileges – Pediatric Nurse

AF Form 2817-1: Clinical Privileges – Pediatric Nurse – AF Form 2817-1: Clinical Privileges – Pediatric Nurse Practitioner is the official U.S. Air Force form used to request, verify, and grant clinical privileges to Pediatric Nurse Practitioners (PNPs) practicing in Air Force Medical Treatment Facilities (MTFs).

This specialized document ensures that PNPs can safely and competently provide care to pediatric patients—from newborns through young adulthood—while aligning with rigorous military healthcare standards for credentialing and privileging.

What Is AF Form 2817-1?

AF Form 2817-1, titled Clinical Privileges – Pediatric Nurse Practitioner, defines the scope and limits of practice for individual advanced practice registered nurses (APRNs) specializing in pediatrics within the Air Force Medical Service (AFMS).

Authority: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102.
Principal Purpose: To document the provider’s requested privileges, have them verified by a clinical supervisor based on credentials and performance, and support formal approval or modification by the credentials committee.

The form is part of the broader Air Force and Defense Health Agency (DHA) credentialing and privileging process governed primarily by AFI 44-119, Medical Quality Operations (and updates aligning with DHA policies). Privileges are facility-specific and based on the provider’s education, training, certification, experience, and demonstrated competence.

Who Uses AF Form 2817-1?

  • Active Duty, Reserve, or Guard Pediatric Nurse Practitioners assigned to or applying for practice in Air Force MTFs.
  • Civilian or contract PNPs seeking clinical privileges in military facilities.
  • Newly graduated or transitioning PNPs completing credentialing packets (often paired with DHA Form 367).

The form helps ensure only qualified providers deliver care to military children and families in outpatient clinics, inpatient settings, or deployed environments.

How the AF Form 2817-1 Process Works?

The process follows standardized codes and steps:

Codes used on the form:

  • 1 — Fully competent within defined scope of practice.
  • 2 — Supervision required (e.g., due to limited recent experience).
  • 3 — Not approved due to lack of facility support (reserved for credentials committee).
  • 4 — Not requested/approved due to lack of expertise, proficiency, or physical limitation.

Steps:

  1. Applicant (PNP) completes Part I: Enters the appropriate code (1, 2, or 4) for each requested privilege. This reflects current personal capability, not facility limitations. The applicant signs and dates the form.
  2. Clinical Supervisor reviews using the facility’s master privileges list and enters verified codes (1, 2, 3, or 4) in Part I. In Part II, the supervisor recommends approval, approval with modification, or disapproval. The supervisor signs and forwards the form to the Credentials Office.
  3. Credentials Committee / Function reviews the package, including primary source verification of education, licensure, certification (e.g., PNCB or ANCC pediatric certifications), training, and performance data. They make the final determination on granting privileges.
  4. Approved privileges are documented and become part of the provider’s credentials file. Ongoing monitoring includes Focused Professional Practice Evaluation (FPPE) for new privileges and Ongoing Professional Practice Evaluation (OPPE).

Recent Military Health System (MHS) changes (effective 2025) allow streamlined portability of privileges across MHS facilities with an attestation process, reducing administrative burden when providers move between locations.

Typical Privileges for Pediatric Nurse Practitioners

While the exact list appears on the official form and facility master privilege lists, core privileges for PNPs generally include:

  • Comprehensive assessment, diagnosis, monitoring, treatment, referral, and management of acute, critical, and chronic conditions in pediatric patients (newborns to young adults) in inpatient and/or outpatient settings.
  • Development of treatment plans, health counseling, and education for children and families.
  • Management of well-child care, preventive services, and common pediatric illnesses.
  • Ability to assess and stabilize emergent conditions consistent with medical staff policies.
  • Additional requested privileges (e.g., specific procedures like lumbar puncture in some settings) are evaluated individually based on training and local capability.

Privileges are tailored to the MTF’s capabilities and the provider’s documented competence. Pediatric care in the AFMS emphasizes family-centered care for active duty families.

How to Download and Complete AF Form 2817-1?

Official Download:
Access the current version directly from the Air Force e-Publishing site:
https://static.e-publishing.af.mil/production/1/af_sg/form/af2817-1/af2817-1.pdf

Tips for Completion:

  • Use black ink or type electronically when possible.
  • Reference your facility’s master clinical privilege list.
  • Attach supporting documentation (board certification, licensure, training logs, letters of recommendation).
  • For new graduates, coordinate with program directors and submit within recommended timeframes (e.g., not more than 45 days prior to completion of training where applicable).

Always follow local MTF Credentials Office instructions, as processes may incorporate updated DHA guidance.

Why Proper Privileging Matters?

Accurate completion of AF Form 2817-1 protects patient safety, maintains high standards of care for military dependents, and ensures compliance with federal regulations and accreditation requirements. It also supports provider mobility within the MHS while documenting competence.

Failure to provide required information or discrepancies in credentials can result in delayed or denied privileges.

  • AFI 44-119 – Medical Quality Operations (governs the overall process).
  • Air Force Medical Service Credentials Verification Office guidance.
  • DHA policies on provider credentialing and privileging portability.
  • DoD Master Privilege Lists for Nurse Practitioners (Pediatrics).

Note: Forms and policies evolve. Always verify the latest version on the official Air Force e-Publishing website or consult your local Credentials Manager or SGN (Surgeon General’s Nursing) office for the most current requirements.

Download AF Form 2817-1 here: Official PDF

If you are a Pediatric Nurse Practitioner preparing for assignment to an Air Force MTF or need assistance with the credentialing packet, contact your gaining facility’s Credentials Office early in the process.

This information is for educational purposes and is based on publicly available U.S. Air Force and DHA resources as of 2026. Official guidance should be obtained from authorized military channels.