2025 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 as a panelist for 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 referencing brand names from the educational discussion as part of my CME panel participation.

I will refer to 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. If slides will be shown during the panel discussion, 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

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 or discussion includes information about a product not labeled by the FDA for the use under discussion or that is still investigational.

My Presentation or discussion: (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.

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: [email protected]

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2025 BH Academic Conference Panelist CME Forms