Attachment_J-20_Organization_Conflict_of_Interest_Sample_Disclosure_Format_Template_(1).docx

Attachment J-20 – Organization Conflict of Interest Sample Disclosure Format Template

HHSM-500-2014-RFP-QINNCC

CMS has differentiated the personal conflict of interest (PCI) certification from the organizational conflict of interest certifications for inclusion in the Compliance and Conflict of Interest (COI) sections of proposals in response to CMS requests for proposals. The organizational language is not suited for individuals. This is now a requirement for all Board members and managers. Below is some general guidance for what CMS now looks for in these PCI Certifications, it must be signed and dated;

The PCI includes information regarding each individual’s Immediate Family. “Immediate Family” means spouse, domestic partner, life partner, daughter, son, step-daughter and/or step-son. Disclosing individuals need not seek out information of which they are unaware, they need only disclose to the best of their knowledge and so state. Please provide the following information, and if not applicable, state “none.” Respond to each item individually.

1. A list of your and your Family’s current or known (to you) future employment, contracts or arrangements, regardless of size, held with any insurance organization or subcontractor of an insurance organization, including, the type of work performed, and the period of performance. Note; do not include personal insurance policies.

2. A list of your and your Family’s current or known (to you) future employment, contracts or arrangements, regardless of size, held with any providers or suppliers furnishing health services for which payment may be made under the Medicare program, including the type of work performed, and the period of performance.

3. A list of all of your and your Immediate Family’s financial interests in the following entities, including the percentage of ownership in each entity: health facility, health payer organization, health plan or association, educational institution that owns or is affiliated with a medical school and/or health facility, pharmaceutical company, laboratory, DME supplier, medical transport service, health information technology (HIT, aka EHR) vendor or other provider or supplier of health services

4. A list of all of your and your Immediate Family’s investments in medical companies, healthcare or medical sector funds and other healthcare or medical sector investment vehicles including but not limited to corporations, partnerships, joint ventures and other business entities (dollar amounts not required).

5. A list of other Board of Director and/or equivalent governing body (e.g., board of trustees; board of managers; etc.) position(s) held by you and your Immediate Family and the length of time in the position(s).

These PCI Certifications may be marked “Confidential” and “Proprietary Business Information.” They are due as specified under the contract, annually, with any new appointment to a position referenced above and when revised, due to any new outside appointment or financial action (e.g., divestiture or acquisition of investments or ownership interests) that would render an individual’s existing PCI Certification incomplete and/or inaccurate.

Name (Signed)

Dated