Healthcare COI Form

HEALTHCARE COI FORM

Purpose: This Conflict of Interest (COI) Form is used to disclose any financial, familial, professional, or other relationships that reasonably could affect or appear to affect the judgment of the patient, treating clinicians, researchers, contractors, or staff in the delivery of healthcare or participation in clinical programs. Complete all sections truthfully. Failure to disclose relevant conflicts may result in administrative action where applicable.

Patient Information

Date of birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Relevant)

Conflict of Interest Disclosure

Check all that apply. If none apply, check the first box. For any checked items, provide a detailed description and estimated monetary value where applicable.

  No conflicts to disclose

  Stock ownership or options in healthcare companies related to my care or research

  Consulting, advisory, or paid clinical services from a company related to my care

  Research funding, grants, or sponsored studies with which I or immediate family are associated

  Paid speaker engagements, honoraria, or travel reimbursement from relevant entities

  Ownership interest, patents, or intellectual property that could be affected by clinical decisions

  Immediate family member employment, board membership, or financial relationship relevant to my care

  Gifts, meals, or hospitality from organizations related to services I receive

  Other (explain below)

Mitigation Measures

Describe any steps already taken or proposed to manage, reduce, or eliminate the disclosed conflict(s). Include names of responsible parties and timelines for mitigation.

Authorization and HIPAA Acknowledgment

I certify that the information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that this information will be used by clinical staff and administrative personnel to evaluate and manage any potential conflicts of interest. I understand that I may be asked to provide additional documentation supporting my disclosure.

  I acknowledge receipt of the facility's privacy practices and consent to the use and disclosure of my health information for the purposes related to conflict assessment and mitigation, as allowed by applicable privacy requirements.

Withdrawal: I understand that I may withdraw this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

Certification

By signing below I certify under penalty of law that the disclosures and statements in this form are accurate and complete. I understand that knowingly providing false information may result in corrective action and could affect my care, benefits, or eligibility for programs where conflicts are material.

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