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Intermountain conflict interest form 2025

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The document is a Conflict of Interest and 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 involving family members. The questionnaire emphasizes the importance of transparency in financial interests and mandates updates whenever relevant information changes.

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How to write a declaration of conflict of interest?

Name of party/ individual with whom I may have a direct or indirect potential relationship: Details of my relationship with the party: Type of Conflict (select which apply): Relationship of the conflicted party with the Group: Any other details:

How do you write a conflict of interest declaration?

Intermountain Healthcare violated provisions of the Stark statute designed to prevent referral arrangements that could provide perverse incentives for personal profit in health care.

How to write a conflict of interest statement?

Self-dealing is the most common type of conflict of interest in the business world. It occurs when a management-level professional accepts a transaction from another organization that benefits the manager and harms the company or the companys clients. Gift issuance is also a very common conflict of interest.

What is a conflict of interest form?

Intermountain employees will not engage in outside activities that will create an actual or apparent Conflict of Interest with the work or mission of Intermountain unless such activities have been disclosed, reviewed, approved, and/or had specific controls put in place by Intermountain management to manage the

What is an example of a declaration of interest statement?

I declare that: I am aware that my information has been collected for the purpose of identifying material personal interests that could influence, or could be seen to influence, the decisions that the employee covered by the declarations policy takes or the advice he/she gives.

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What is the conflict of interest policy in Intermountain Health?

State the reasons why you think these interests could, or could be seen to, influence your decisions, actions or advice. Finally, set out the steps you intend to take, or which you may require others in the department to take, to mitigate any conflict arising. Attach supporting documentation if required.

Intermountain conflict interest form 2025

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