LUGPA Conflict of Interest Disclosure Form Instructions

  • Carefully review the LUGPA Conflict of Interest Policy on the following page.
  • There are two sections in this form:
    • In the first section, you will disclose the names of proprietary entities producing health care goods or services, with the exception of non‐profit or government organizations and non‐health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.

      Explain what you or your spouse/partner received, specify your role, and indicate the appropriate tier of compensation received.

    • In the second section, you will disclose the names of proprietary entities producing health care goods or services, with the exception of non‐profit or government organizations and non‐health care related companies with which your group has, or has had, a relevant financial relationship within the past 12 months.

    • You may disclose up to 50 relationships in each section.

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