May 21, 2018

RITZ RAY G. ALAVA

Department Head
Medical Records Department
Iloilo Doctors’ Hospital

Dear Sir:

Greetings!

I am Martin Federic Palco, presently a Post Graduate Intern. I have completed my

Clinical Clerkship rotation (SY 2016-2017) in this institution. I would like to ask
permission to pull-out the patients’ charts of the following patients, and to
photocopy the said documents, as part of our academic requirement in the
completion of Clinical Clerkship and Physicians Licensure Examination.

NAME OF PATIENT CASE NUMBER DATE OF OPERATION

I assure you that patients’ records will be treated with utmost respect and guarantee
patient privacy. The said documents will be submitted to proper authorities only and
will not be shared with anybody else.

Hoping for your positive response.

Respectfully yours,

MARTIN FEDERIC M. PALCO

Post Graduate Intern - IDH

Noted:

LUDOVICO JURAO JR., MD

Assistant Administrator for Patient Care
Dean, Iloilo Doctors’ College of Medicine