All Governing Body members, committee members, and staff of the Agency will disclose any potential conflict of interest.
To ensure Governing Body members, committee members and staff perform in an ethical manner.
Any outside interest that could possibly involve a conflict of interest (directly or indirectly) with any person, vendor, patient, family, purchaser or competitor will be disclosed.
The nature of outside interests may be determined as(Required)

If a conflict or potential conflict of interest arises for a staff member, the staff member must immediately reveal the conflict to his/her immediate supervisor.

The Agency will review its relationships and staff’s relationships with other care providers, educational institutions and payers to ensure that those relationships are according to applicable law and regulation and to determine if conflicts of interest exist.

All Governing Body members, committee members and staff of the Agency will act in the course of their duties solely in the best interests of the organization without consideration to the interests of any other Agency, organization, or association with which they are associated, and refrain from taking part in any transaction where such person(s) do not believe in good faith that they can act with undivided loyalty to the Agency.

The members of the Governing Body and all staff provide written disclosure of all professional or personal relationships or interests, direct or indirect that might present a conflict of interest.

In the event that a Governing Body and/or committee member has a conflict regarding a matter that requires voting, the individual with a conflict of interest shall be excluded from the vote.

Attestation Statement: I have read the Conflict of Interest policy set forth above and agree to comply fully with its terms and conditions at all times during my service as an employee or Governing Body/committee member. If at any time following the submission of this form, I become aware of any actual or potential conflicts of interest, or if the information provided below becomes inaccurate or incomplete, I will promptly notify the Administrator in writing.

MM slash DD slash YYYY