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DELINEATION OF CLINICAL PRIVILEGES PEDIATRICS 1. NAME OF PROVIDER (Last, First, MI) For use of this form, see AR 40-68; the proponent agency is OSG 2. RANK/GRADE 3. FACILITY INSTRUCTIONS: PROVIDER:

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What is name of provider?

Name of provider refers to the individual or entity that is providing a service or goods.

Who is required to file name of provider?

Any individual or entity that is providing a service or goods is required to file name of provider.

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Name of provider can be filled out by providing the legal name or business name of the individual or entity providing the service or goods.

What is the purpose of name of provider?

The purpose of name of provider is to identify the individual or entity that is providing the service or goods.

What information must be reported on name of provider?

The information that must be reported on name of provider includes the legal name or business name of the provider.

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