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Conflict of interest disclosure form

Intermountain conflict interest form 2026

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The document is a Conflict of Interest / Independence Questionnaire for Fiduciaries associated with Intermountain Healthcare. It requires trustees to disclose their employment, positions of influence, and any potential conflicts of interest, including those related to family members. The questionnaire emphasizes the importance of transparency in financial interests and responsibilities to ensure ethical governance within the organization.

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Click ‘Get Form’ to open the intermountain conflict interest form in the editor.
Begin with Part 1: General Information. Fill in your name and today's date. Ensure all fields are completed; if a question does not apply, write 'NA'.
Proceed to Part 2: Potential Conflicts of Interest. Answer each question regarding your employment and positions of influence. Be thorough in listing employers and job titles.
For questions about family members, provide accurate details about their employment and any potential conflicts of interest. This includes their positions and relationships to you.
Review your responses for accuracy before signing at the bottom of the form. Ensure that you have answered all questions to the best of your knowledge.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the 6 values of Intermountain Healthcare?

Values Integrity. We are principled, honest, and ethical, and we do the right thing for those we serve. Trust. We count on and support one another individually and as team members. Excellence. We perform at the highest level, always learning and looking for ways to improve. Accountability. Mutual respect. Equality.

Who is the CEO of Intermountain Healthcare?

Robert W. Allen (Dec 1, 2022) Intermountain Health / CEO

Does Intermountain use Cerner?

Rob Allen is president and CEO of Intermountain Health. He has served in executive leadership roles at Intermountain for 27 years of his 30+ year health leadership career.

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