Conflict of Interest Disclosure Form
AHCCCS requires speakers to disclose any conflicts of interest prior to a presentation. A conflict of interest does NOT
necessarily disqualify you from participation. The speaker agrees to inform attendees of any conflict of interest. The conflict
must be disclosed in the presentation materials or at the onset of the lecture. You must also follow our instructions to
resolve/manage your conflict of interest.
General Information and Your Role
Activity Title: Activity Date(s):
Name: Title:
Email: Phone Number:
Title of Your Presentation(s) and/or Topic(s):
Please Disclose Any Relevant Financial Relationship
1. Are you an employee or principal member of a company that is testing, producing, marketing,
re-selling or distributing health care goods or services?
2. Do you receive currently, or have you received in the past 12 months, payments from a company for
any of the following or similar work you provided: speakers’ bureau, consultant, grant/research, etc.
3. In your presentation, will you discuss any products or services that were developed by a commercial
interest (e.g. pharmaceutical company or devise manufacturer) with which, within the past 12
months, you, your spouse, or your partner have had a financial relationship?
4. Will you be discussing off-label use(s) of a medication? If so, identify the medication, off-label use,
and manufacturer.
5. Do you have any other kind of financial interest in products or services you will be discussing?
If you answered “Yes” to any of the above, please list the commercial interest(s) and define your relationship(s)
(e.g., founder, chief medical officer, speakers’ bureau, consultant, research support, stocker holder, royalties, or
similar).
Commercial Interest: Relationship:
Your Attestation
Regardless of any relevant financial relationships disclosed above, I attest that the content for this activity will provide a
well-balanced, evidence-based, and unbiased approach to diagnostic and therapeutic options related to quality health care.
I agree to inform attendees of any conflict of interest and will disclose in the presentation materials or at the outset of the
lecture.
Your Signature: Date of Signature:
Updated: 7/9/2019
YES NO
YES NO
YES NO
YES NO
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