Date

To: Dr.
Chief Executive Officer/ Head Infectious Diseases
________________Hospital

Good day!

We are 2nd year students of Centro Escolar University School of Medicine

We would like to request permission to conduct a study that involves the review of medical records on
the Hospital.

The request is provided to you in terms of the requirements of the Health Privacy Code Specifying the
Joint A.O. No. 2016-0002 “Privacy Guidelines for the Implementation of the Philippine Health
Information Exchange”

The title of the study is:

The researchers would like to request access to the following information:

 Access to the clinical files, record book and the data base.

We intend to present the findings of the study in a classroom setting as well as publish in a professional
journal and/ or at professional meeting like symposia, congresses, or other meetings of such a nature
(pag may chance)

We intend to protect the confidentiality of the institutution as well as the personal identity of the
patients by assigning a random code for the hospital and number for the patients.

We undertake not to proceed with the study until we have received approval from the Ethics Review
Board of Centro Escolar University-School of Medicine.

Very Sincerely Yours,

The Researchers.