Appendix T – Application for Away Rotation

Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to l
Page 1 of 4
Other Institutions
Date Revised: January 2001, November
2009, January 2015, May 2025
Application Procedure for
SSM Health/Saint Louis University School of Medicine Residents (SSM Health/SLUSOM)
Rotating to Other Institutions for Electives
External elective rotations for residents and fellows of SSM Health/SLUSOM’s Graduate Medical Education
(GME) Programs are only available on a case by case basis and with prior approval.
Applications will be
considered only for educational experiences which cannot be provided at SSM Health/SLUSOM or one of its
affiliated institutions. The electives should be for specific educational components which are critical to the
trainees’ future professional development.
Applications will only be considered from trainees who have already demonstrated mastery of PGY level goals
and objectives and have met or made substantial progress towards specialty or subspecialty board certification.
Because of the nature of funding for Graduate Medical Education, neither SSM Health nor its affiliated institutions
can receive Medicare or Medicaid reimbursement for stipends, benefits, malpractice, or other teaching and
administrative costs while one of our trainees is away on an elective. (See Section 1.5 subsection III, Funding
for Residency Training Programs). The malpractice coverage for trainees must be secured in advance while
training at a new clinical site or new institution (see Health Professions Letter of Indemnity). Malpractice coverage
is not available for non U.S. rotation sites.
The accepting institution for an elective is rarely able to receive governmental support for the above costs no
Medicare or Medicaid cost report, BBA 97 restrictions, etc.). For these and other reasons, alternative funding
and/or GME approval must be secured in advance of the away rotation experience.
Planning for these electives typically takes 3-6 months. Even funded and otherwise acceptable requests may
not be approved if the initial completed request (Section I-II, see below) is not received 3 months prior to the
projected start date of the elective.
Application procedures are as follows:

1. A separate application must be completed for each elective rotation.
2. Each application must be completed including resident data verifications and appropriate
   signatures before approval is given.

Applicant is to complete Section I of the application and is responsible for requesting completion of
Section II by the SSM Health/SLUSOM Residency Program Director. Applicant will then forward the
application to the Residency Program Director or Clinical Supervisor where the elective will be take for
completion of Section III and returned to the SSM Health/SLUSOM Residency Program Director.
The Program Director will forward the application to the SSM Health/SLUSOM Medicine GME Office for
completion of Section IV.
The original is to be kept in the SSM Health/SLUSOM GME office and copies forwarded to the applicant
and the elective residency program director.

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Section III To be completed bythe Residency Program Directoror Clinical Supervisor atthe Awi
Elective site. After completion, please send this application to the applicant’s SS
Health/SLUSOM Residency Program Director.

1. The resident has approval to take this elective rotation indicated below. _ Yes
   _No
   Dates of rotation:
2. Will an ACGME Program Letter of Agreement or Institutional Affiliation Agreement be required for th
   Away Rotation _Yes No
3. Will malpractice coverage be provided by the Away Elective Site _Yes_No

For non-Missouri sites: will a state training license be needed
_Yes
No
5.
Name of residency program director (if applicable)
Name of sponsoring institution (if applicable).
Name of physician supervising resident:
(Print)
(Signature)
Date
Name of DIO/Site/Hospital/Institutional Official:
(Print)
(Signature)
Date

Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to
Other Institutions
Date Revised: January 2001, January
2015, April 2025
Page 4 of 4
Section IV To be completed by SSM Health/ SLUSOM Administration.

1. Malpractice insurance
   is not extended to cover the resident while the resident is on this elective
   rotation. (See attached Letter of Indemnity.)
2. The resident has our approval to take this elective.
   Sr. Associate Dean, SSM Health/Saint Louis University School of Medicine
   Date
   SSM Health/Saint Louis University School of Medicine
   Name of Sponsor
   1402 South Grand Boulevard, Room M260
   Mailing Address
   St. Louis, Missour 63104
   City, State, Zip Code
   314-617-2359
   Telephone
   314-617-2534
   Fax
   FOR SSM Health / SLUSOM GME Office:
   Please check off:
   Copies sent by SSM Health/SLUSOM to:
   Applicant
   SSM Health/SLUSOM Residency Program Director
   Elective Program/Rotation Director