Healthcare Conflict of Interest Declaration

Healthcare Conflict of Interest Declaration

This declaration must be completed by all clinical staff, researchers, contractors, and any personnel whose duties may influence patient care, purchasing, referrals, research, or vendor selection. Failure to disclose a potential conflict of interest or knowingly submitting false information may result in administrative disciplinary action, up to and including termination, and may require remedial measures to eliminate or mitigate the conflict.

Declarant Information

Full legal name:

Employment status:    Employee ID (if applicable):

Contact & Optional Patient Information

Is this disclosure related to a specific patient or patient account? Yes    No

Patient Date of Birth (if applicable):

Disclosure of Interests

Describe any financial interests, relationships, or activities that could reasonably be perceived to influence your professional responsibilities. Disclose all relevant details below. Continue on an attachment if necessary and label as "Attachment A."

Categories of interest (check all that apply) and provide details where requested:

Equity / Ownership interest in a healthcare-related company

Consulting, advisory board, or paid speaking engagements

Research funding, clinical trial support, or sponsored activities

Gifts, hospitality, or honoraria from vendors or industry

Family member or close personal relationship that may influence care or procurement decisions

Other (describe below)

Management & Remedies

I understand that upon review, the organization may determine that mitigation is required, including but not limited to: reassignment of duties, recusal from specific patient care, disclosure to patients, termination of financial arrangements, or other corrective actions. I agree to cooperate with any reasonable remedy and to provide additional documentation upon request.

Certifications, Acknowledgements, and Privacy

By signing below I certify, under penalty of policy-imposed discipline, that the information provided in this declaration is true, complete, and accurate to the best of my knowledge. I further acknowledge my continuing obligation to update this declaration promptly if circumstances change or new information arises that may create a potential conflict, ordinarily within 30 calendar days.

I acknowledge that information contained in this declaration may be reviewed by authorized compliance personnel and, when necessary, disclosed to relevant oversight committees, supervisors, and, where required, patients or third parties as part of legitimate conflict management. Such disclosures will be limited to information necessary to manage the conflict and will otherwise be treated in accordance with applicable privacy and confidentiality rules.

HIPAA / Privacy acknowledgement: I acknowledge that any patient-identifiable information disclosed on this form is submitted in accordance with applicable privacy rules and that I have the authority to disclose such information for compliance review.

Previous Disclosures

Have you previously disclosed this matter to the organization? Yes    No

Attestation

I attest that I have reviewed applicable policies and that I will promptly notify my supervisor and compliance office of any change that may create a new conflict of interest. I understand that insufficient disclosure may require corrective action.

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