SAMPLE ON DEPARTMENTAL LETTERHEAD

M E M O R A N D U M 

TO:	Dean, Medical College of Georgia

Senior Associate Dean, Graduate Medical Education and VA Affairs

FROM:	Name of sending Chairperson or Program Director
Address of Department

RE:	Clinical Educational Rotation Request for (name of House Officer)

DATE:	May 1, 2016

I have approved (name of House Officer) to perform an elective clinical rotation under the supervision of (name of supervising medical staff member), in the (name of clinical service/address) during the time frame of (start date and ending date).  The purpose of this elective clinical rotation will be                                                               , which I believe will be of benefit to his/her residency training activities.

I am attaching a certificate of insurance for (name of House Officer) which verifies their professional liability in the minimum amounts of $1M/$3M.  If you have any questions regarding this elective clinical rotation, you may contact me at (phone # of sending Program Director). 

Approved:

The House Officer is responsible for obtaining a medical license (if required) before performing the rotation. 

_____________________________________	______________________________
House Officer					Date:

                                                                           	______________________________
Manager, MCG Residency Programs                           Date:

_____________________________________             ______________________________
Senior Associate Dean				Date:
Graduate Medical Education and VA Affairs
Medical College of Georgia 
Augusta University

_____________________________________            	 ______________________________
Dean, Medical College of Georgia                               	 Date:
Augusta University

cc:	Director, Health Information Management
Graduate Medical Education Office