ESBD_383080_1731698257370_EXHIBIT J - Business and Financial Relationship Disclosure.pdf

Exhibit J

BUSINESS AND FINANCIAL RELATIONSHIP DISCLOSURE FORM

Directions: If Consultant has a financial relationship with a Central Health partner* (listed on the back page of this form), has done business with a Central Health partner during the 365-day period immediately prior to receiving this renewal letter, or expects it will do business with a Central Health partner during this renewal term, Consultant shall complete and submit this form.

1. In the space provided, print the name(s) of all Central Health partner(s) with whom you have a financial relationship or have done business in the past 365 days.

2. In the space provided, print the name(s) of all Central Health partner(s) with whom you expect to do business or have a financial relationship with during the renewal term of this Agreement.

• a

• b

• c

• d

• e

• f

• g

• i

• j

• k

• l

3. To the extent applicable, use the space provided below to describe (a) the work you are performing for the Central

Health partner, (b) when the work commenced or will commence, (c) when the work was completed or is expected to be completed, (d) the total compensation paid or expected to be paid as a result of the work, and (e) the division, group, team, or other unit who performed or will perform the work for the Central Health partner.

a. ____________________________________________________________________________________________

b. ____________________________________________________________________________________________

c. ____________________________________________________________________________________________

d. ____________________________________________________________________________________________

e. ____________________________________________________________________________________________

Printed name:

Consultant’s Signature:

Date: _________________

*Note: The use of the term partner is not meant to convey that Central Health has formed a new business entity with the organizations listed on the back of this form. Rather, it is meant to convey that Central Health has a contract, or is otherwise affiliated, with the named organizations.

The successful bidder will be required to sign this form.

LIST OF CENTRAL HEALTH PARTNERS

• Central Texas Community Health Centers (d/b/a CommUnityCare)

• Community Care Collaborative (CCC)

• Sendero Health Plans

• Seton Healthcare Family

• St. David’s HealthCare

• Ascension Health

• Hospital Corporation of America (HCA)

• University of Texas System

• Dell Medical School at the University of Texas at Austin

• Integral Care (ATCIC)

• Travis County

• City of Austin

• Deer Oaks

• Planned Parenthood of Greater Texas

• Health Alliance for Austin Musicians (HAAM)

• SIMS Foundation