Affiliation agreements are necessary when a sponsoring institution makes arrangements for all or part of the education elements of an internship or residency program to be delivered at another hospital. The sponsoring institution may be a college of osteopathic medicine or an osteopathic hospital. Some basic considerations, which are outlined herein, should be reviewed when the sponsoring institution enters such agreements. Some of these considerations are requirements of the American Osteopathic Association, while others are necessary to avoid later complications. Agreement should be reached on negotiable factors, accepted by both institutions, and then referred for legal review by appropriate authorities.