Author/Presenter Disclosures and Attestation

Primary Care Focus Symposium Online

Author or Presenter's 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.

I agree to the following statements: *

I will provide a balanced and objective view of all therapeutic options and will not promote a specific proprietary business interest of an ineligible company.

I will provide the type of evidence and references that support each key teaching point.

All recommendations involving clinical medicine will be supported by evidence that is accepted within the profession of medicine as adequate justification for indications and contraindications in the care of patients.

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.

B. Online Posting for e-Posters

Baptist Health CME provides registered attendees with access to e-Posters in digital format on the Baptist Health CME portal before and after the symposium. Access will be shared only with symposium attendees and faculty and will be available from July 2021 to July 2022.

NOTE: We cannot post e-Posters which are not compliant with laws related to copyright/fair use, HIPAA or PHI.

Do you agree to have a digital version of your e-Poster posted online and made available to attendees? *

Yes

C. e-Poster Guidelines

My e-Poster will include: *

Disclosure of Relevant Financial Relationships

Learning Objectives

Summary: Key Learning Points with References

Citations and References (evidence-based, peer-reviewed)

D. HIPAA & PHI (Protected Health Information) Laws

I take responsibility for compliance with HIPAA Privacy requirements and applicable state and United States federal laws protecting confidentiality and security of PHI and safeguarding PHI.

I agree to the following statements: *

I have removed all Personal Health Information (PHI) or de-identified images used in my materials including photographs as well as dates of patient care or birth dates (typically found in the margins of clinical images).

When presenting specific patient cases or case histories, I warrant that I have obtained HIPAA compliant authorization for any PHI in my presentation materials.

If my presentation will contain patient identifiers, it is my responsibility to obtain consent from my patients for use of their PHI, including photographic images.

E. Copyright/Fair Use Laws

I agree to the following statements: *

I have obtained permission from copyright holder(s) to reproduce/copy from their work. I acknowledge that Baptist Health South Florida (BHSF) will not be held legally responsible for any misrepresentation on my part regarding copyright infringement.

F. Unlabeled / Unapproved Use

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

My e-Poster: *

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

The Baptist Health South Florida Continuing Medical Education Program, an ACCME-accredited CME provider, operates within the framework of the Standards for Integrity and Independence to ensure balance, independence, objectivity and scientific rigor in all of its CME activities. Anyone engaged in content development, planning or presentation is obliged to complete this form. Persons who refuse to return this completed form in a timely manner may not participate in the CME activity.

Relevant Financial Relationships

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 an entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. The ACCME does not consider providers of clinical services directly to patients to be ineligible companies.
The ACCME focuses on relevant financial relationships with ineligible companies in the 24-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity.

Please check the option that applies to you. *

Neither I, the undersigned, nor my spouse/partner, have/had any relevant financial or other relationship(s) with an ineligible company (as defined above) now or within the past 12 months.

Within the past 12 months, I, the undersigned, and/or my spouse/partner, had a relevant financial relationship, arrangement and/or affiliation with the organizations or companies noted below.

Indicate below the company(ies) with which you or your spouse/partner have (or had) relevant 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 an employee/owner of: *

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.

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Author/Presenter Disclosures and Attestation - Primary Care Focus Symposium Online