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 DIO

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

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

DATE:	__/__/__

I have approved (name of House Staff) to perform an elective clinical rotation under the supervision of (name of supervising medical staff member) at (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 their GME training activities.

I am attaching a certificate of insurance for (name of House Staff) 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 Staff is responsible for obtaining a medical license (if required) as well as all other applicable requirements in a timely fashion before performing the rotation. 

_____________________________________	______________________________
House Staff					Date:

                                                                           	______________________________
Manager                                                                        Date:
MCG Residency Programs                           
                 
_____________________________________             ______________________________
Natasha M. Savage, MD				Date:
Senior Associate Dean	
Graduate Medical Education and DIO
Medical College of Georgia 
Augusta University

_____________________________________            	 ______________________________
David C. Hess, MD    				 Date:
Dean, Medical College of Georgia                               	 
Augusta University

cc:	Director, Health Information Management
Graduate Medical Education Office