Faculty Disclosures 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. 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 MonthOct Day Day13 Year Year2024 Need to contact us?Baptist Health CMEBaptist Health Education CenterBaptist Hospital8900 North Kendall DriveMiami, FL 33176Phone: 786-596-2398Fax: 786-533-9821Email: CME12@BaptistHealth.net Leave this field blank