PLEASE ONLY FILL THIS FORM ONCE REGARDLESS OF THE POTENTIAL NUMBER OF YOUR ROLES IN PTCOG 60 & PTOCG-NA 8.
Baptist Health South Florida, an ACCME accredited CME provider, operates within the framework of the Standards for Integrity and Independence in Accredited Continuing Education to insure balance, independence, objectivity and scientific rigor in all of its CME activities.
Anyone engaged in content development, planning, review or presentation is obliged to complete this form. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

Should you have any questions, please do not hesitate to contact us at program@ptcog60.org.

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* Personal Details

**Please make sure to use the same email address to which you received our request for filling in this form.

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* PTCOG 60 Role (check all that apply)

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* Within the past 24 months, have you had any financial relationship(s) with ineligible companies?
INELIGIBLE COMPANY is defined as entity whose primary business is producing, marketing, selling, re-selling or distributing healthcare products used by or on patients.
  • There is no minimum financial threshold.
  • You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

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