Disclosure Form and Resolution of Conflict of Interest
Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any ineligible company related to the subject matter of the educational activity. Per ARMA requirements, persons who fail to sign and return this form are not eligible to be involved with this activity.

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* 1. Declaration

I understand that continuing education accreditation guidelines prohibit me from accepting any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CME provider or its educational partner (or fiscal agent).

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* 2. Annual Disclosure for:

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* 3. CME Activity or Activities you participate in:

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* 4. Year or Date of CME Activity:

Dignity Health-EV must ensure balance, independence, objectivity and scientific rigor in its educational activities. List the names of proprietary entities of ineligible companies (definition: those whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients.) with which you have, or have had, a relevant financial relationship* within the past 24 months

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* 5. With respect to this CME activity (check one):

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* 6. Enter the Nature of Financial Relationship and Company Name
Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or names investigator even if that individuals institution received the research grant and manages the funds.

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