Conflict of Interest Disclosure Form - Arkansas Medical Society

Directions: Please complete each question to the best of your knowledge.

Definition: Immediate family member shall mean spouse, parent, or child.

Pursuant to the AMS Conflict of Interest Policy and Guidelines requiring completion of a disclosure statement related to certain affiliations and interests, I hereby provide the following information.

Conflict of Interest Disclosure

Directions: Please complete each question to the best of your knowledge. Definition: Immediate family member shall mean spouse, parent or child. Pursuant to the AMS Conflict of Interest Policy and Guidelines requiring completion of a disclosure statement related to certain affiliations and interests, I hereby provide the following information.

Do you or an immediate family member hold or plan to hold a financial interest in any business which furnishes goods or services, or is seeking to furnish goods or services, to AMS?
If yes to the above, please list the name of each business and the type of goods or services involved.*
Do you or any immediate family member hold or plan to hold a financial interest or employment with a hospital or health system, or interest in an outpatient surgery facility or similar business?
If yes to the above, please list the name of each business or facility.*
Are you or any immediate family member, or do you or any immediate family member anticipate becoming within the next 12 months, a trustee, director, officer, council or committee member, employee, or consultant of any hospital or other health care organization, or health insurance company?
If yes to the above, please list the name of each organization, position held, and term of position. If the organization is not nationally known, please provide a brief description.*
Are you involved in, or do you anticipate being involved in, any advocacy or lobbying on behalf of any other organization?
If yes to the above, please list the name of each organization and describe the nature of the activities in which you are or will be involved.*
Are you or any immediate family member involved in any organizational relationship, activity, or interest which may raise a conflict of interest or impair your objectivity on AMS policies or issues?
If yes, please describe the organizational relationship, activity, or interest.*
Acknowledgement: I have read and will abide by the AMS Conflict of Interest Policy and Guidelines. Enter first and last name to sign.
First Last