2024 BH Academic Conference Panelist CME Forms

Course Name: *

Faculty Name and Professional Title: *

Please list your name and title as they should appear on the website and other promotional materials.

Mobile Number: *

Please enter your contact information so that we can reach you while you're traveling.

Agreement

A. Unbiased and Independent Content

I agree to uphold academic standards to insure independence and scientific rigor in my role in the development and presentation of this CME & CE activity.

This includes the expectations that: *

As an important contributor to our accredited education, we would like to enlist your help to ensure that educational content is fair and balanced, and that any clinical content presented supports safe, effective patient care.

All recommendations for patient care in accredited continuing education must be based on current science, evidence and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.

All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.

Although accredited continuing education is an appropriate place to discuss, debate, and explore new and evolving topics, these areas need to be clearly identified as such within the program and individual presentations.

I will omit company logos and brand names from the educational materials that are part of my CME presentation, such as slides, abstracts and handouts.

I will use generic names wherever possible.

C. HIPAA & PHI (Protected Health Information) Laws

It is the responsibility of the faculty to comply with HIPAA laws, and they are liable in case of any privacy breach that violates HIPAA regulations. Faculty members are expected to remove all identifying information from presentation materials. If presentations require the use of patient images for effective teaching, presenters must obtain patient consent as required by HIPAA.

E. Unlabeled / Unapproved Use

Although accredited continuing education is an appropriate place to discuss, debate, and explore new and evolving topics, these areas need to be clearly identified as such within the program and individual presentations. It is the responsibility of accredited providers to facilitate engagement with these topics without advocating for, or promoting, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.

I agree to disclose to the audience if my presentation includes information about a product not labeled by the FDA for the use under discussion or that is still investigational.

My Presentation: (check one) *

Select one.

DOES NOT include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

DOES include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose.

F. Baptist Health CME Portal Learning Management System Consent to Video

I, the undersigned, do hereby voluntarily participate and give authorization for myself to appear in filming, photographs, videotaping, audiotaping and/or interviews for medical, clinical, and hospital education and training. I do hereby consent to the specific use of such production, which includes my name, likeness, and the content I present, for continuing medical education.

I do hereby release Baptist Health South Florida, its agents, and its employees from all liability in connection with the above-referenced educational content. I waive any right to inspect or approve the finished product or the advertising or other copy that may be used in connection with the educational content produced. I hereby consent to the use of such content for continuing medical education, without expectation of remuneration to me now or in the future, and this shall be binding upon my heirs, personal representatives and assigns.

Specific Use: The video and/or audio recording will be used strictly for non-profit educational purposes of the Baptist Health South Florida Continuing Medical Education Department described above. It will not be sold to a third party, individually or in combination with other presentations, as an educational tool now or anytime in the future.

Please Initial *

Disclosures

Baptist Health South Florida, an ACCME accredited CME provider, operates within the framework of the Standards for Integrity and Independence in Accredited Continuing Education to insure balance, independence, objectivity and scientific rigor in all of its CME activities. Anyone engaged in content development, planning, review or presentation is obliged to complete this form. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

Circumstances create a conflict of interest when an individual has an opportunity to influence or control CME content about products or services of an ineligible company with which he/she has a financial relationship.
The ACCME defines an “ineligible company” as any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
ACCME requires that faculty disclose all financial relationships that you have had in the past 24 months with ineligible companies.

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s).
There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.
NOTICE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest".

Please check the option that applies to you. *

I, the undersigned, have not had any financial or other relationship(s) with an ineligible company (as defined above) now or within the past 24 months.

Within the past 24 months, I, the undersigned, had a financial relationship, arrangement and/or affiliation with the organizations or companies noted below.

Indicate below the company(ies) with which you have (or had) financial relationships and your role, affiliation or financial interest with that company. *

NOTE: Please do not disclose actual financial value of affiliations. Diversified mutual funds are not included in the definition of "commercial interest."

I have received grant/research support from: *

I am a consultant for: *

I am a contractor for: *

I am an advisor for: *

I am an employee/owner of: *

I am an executive of: *

I am the owner of: *

I receive royalties or am a patent beneficiary from: *

I am on the speakers' bureau for: *

I own stock in or am a shareholder of: *

I have other relevant financial relationships to disclose: *

Attestation

I attest that the information provided above is true and correct and that I have read and agree to all the terms of this Invitation as stated and described herein. *

Please sign your name.

Email *

Date *

Month

Day

Year

Need to contact us?

Baptist Health CME
8940 North Kendall Drive
Suite 702E
Miami, FL 33176

Phone: 786-596-2398
Fax: 786-533-9821
Email: CME12@BaptistHealth.net

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2024 BH Academic Conference Panelist CME Forms