CLINICAL AUTHORIZATION LETTER (CAL)

U.S. Clinical Clerkships for Visiting Students or Residents in Training

COMPLETION OF THIS FORM BY A MEDICAL SCHOOL or RESIDENCY PROGRAM IS MANDATORY SUBJECT TO FINAL APPROVAL BY
AMERICLERKSHIPS MEDICAL SOCIETY (AMS)
*Indicates a required field ** Requires approvals which may cause delays
IMPORTANT NOTICE TO MEDICAL SCHOOL or RESIDENCY: AMS is requesting information regarding the named visiting Medical Student or
Residents (hereinafter Applicant) clinical clerkships and the Medical School or Residencys (hereinafter Sponsor) requirements. The purpose of
this CAL is to insure that the Applicant is in good standing and in compliance with the Sponsors policies regarding away clinical clerkships. This
form is to be completed by an official in charge of clinical clerkships such as Chief Medical Officer, Program Director, Dean of Clinicals or other
official in a similar position. This is not an Affiliation Agreement for Teaching Hospital Guarantee Verified clinicals. All AMS rules, regulations,
policies, agreements and disclosures apply, and the Sponsors request for any special consideration or requirements may not supersede those
stated on this CAL, nor AMS Membership Agreement. Please send this completed and sealed CAL, along with a Letter of Good Standing on
official letterhead to:
AmeriClerkships Medical Society
Attention: Clinical Enrollment Department
26 Executive Park, Suite 270, Irvine, CA 92614 USA
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Name of Sponsor*:________________________________________ Accredited by*:_______________________________________________

Name of Applicants medical school as it appears in imed.faimer.org*:
________________
Is this medical school recognized by the Medical Board of California (medbd.ca.gov/applicant/schools_recognized.html)*?
No

Yes
Sponsors Representative Name*:
Title at Sponsoring Institution*:
and Email*:
Representatives Telephone Number*:
Clinical Coordinators Name (if different than above):
_____________________
and Email:
Coordinators Telephone Number:
Applicants Name*:
Date of Birth*:
Is the Applicant in good financial and academic standing with the Sponsor*?

No

Yes
Does this Sponsor give consent to Applicant to complete insured teaching-attending-physician supervised hands-on clinical clerkships
administrated by AmeriClerkships Medical Society in the United States*?

No

Yes
11. Indicate the clinical clerkship specialty, hours/week and total weeks that the Sponsor is giving consent to*:

Clinical Block #1 Specialty:

Hours/Week
Total Weeks

Clinical Block #2 Specialty:

Hours/Week
Total Weeks

Clinical Block #3 Specialty:

Hours/Week
Total Weeks

Clinical Block #4 Specialty:

Hours/Week
Total Weeks

Clinical Block #5 Specialty:

Hours/Week
Total Weeks

Clinical Block #6 Specialty:

Hours/Week
Total Weeks

Clinical Block #7 Specialty:

Hours/Week
Total Weeks
Hours/Week
Total Weeks

Clinical Block #8 Specialty:

12. Financially responsible party for all clinical blocks outlined above*?

Applicant

Sponsor

Other:______________
13. This Sponsor REQUIRES the following in order for the Applicant to receive credit for their U.S. clinical clerkships*:

Clinical sites name must appears as a Sponsor, Major or

Scrub in surgical cases (depends on specialty)
Other Participating Institution in www.ACGME.org

Learn current U.S. Evidence Based Medicine

Internal Medicine must be 100% inpatient (Hospitalist)**

Document Applicant through hospitals Medical Staff Office (or

Internal Medicine must be inpatient and outpatient (clinics)
equivalent) for future verification** An agreements between
AmeriClerkships Medical Society and Sponsor is required

Clerkships may mirror that of U.S. medical students

Work with other medical students and residents

Must have Intensive Care Unit (ICU) experience**

Pre-clinical documents that need signatures (please attach)

Learn how to better apply to U.S. residency programs

Government approval (please attach documents)

Be on-call every _____ days

Other: __________________________________________

Become familiar with SOAP note format

Other: __________________________________________

Go to local residency & hospital grand rounds**

Other: __________________________________________

Perform weekly case presentations
Signature of Sponsor*

Signature of Applicant*

Signature:

Date:

Signature:

Date:

Print Full Name:

Title:

Print Full Name:

Title:

Official
Corporate Seal of
Sponsor
Required

Final Verification by AmeriClerkships Medical Society*

Signature:

Date:

Print Full Name:

Title: Chief Clinical Officer