BRRH Commitee Faculty Disclosures with Video Consent Activity Name: * Faculty Name * Please list your name as it should appear on the website and other promotional materials. Title and Affiliations * Please add your Professional title and affiliations Mobile Number: * Please enter your contact information so that we can reach you while you're traveling. F. Baptist Health CME Portal Learning Management System Consent to VideoI, the undersigned, voluntarily agree to participate in and give authorization for myself to be filmed, photographed, videotaped, audiotaped, and/or interviewed during the Baptist Health South Florida monthly committee meetings. I understand that these recordings will be used for internal purposes. I, the undersigned, also 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 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. I 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, including any advertising or promotional materials that may be used in connection with the educational content produced. I consent to the use of such content for continuing medical education without expectation of remuneration, either now or in the future, and this consent shall be binding upon my heirs, personal representatives, and assigns. Specific Use:The video and/or audio recordings will be used strictly for internal purposes by the Baptist Health South Florida Continuing Medical Education Department. These recordings will serve as an internal resource for CME purposes, allowing the CME office to review and reference the content of the meetings. The recordings will not be distributed to third parties or sold, either individually or in combination with other presentations, now or in the future. Please select one: * Yes, I consent to the specific use noted above by Baptist Health CME Portal Learning Management System I do not consent to the use of the video / audio recording of my presentation to Baptist Health CME Portal Learning Management System Please Initial * DisclosuresBaptist 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." Advisor Consultant Employee Executive Role Independent Contractor Individual Stocks/ Stocks Option Ownership Researcher Royalties or Patent Beneficiary Speaker Other 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 MonthMar Day Day16 Year Year2025 Need to contact us?Baptist Health CMEBaptist Health Education CenterBaptist Hospital8900 North Kendall DriveMiami, FL 33176Phone: 786-596-2398Fax: 786-533-9821Email: [email protected] Leave this field blank