Insert Symposium Name Here - Speaker Confirmation and Faculty Planning Forms with Disclosure and Video Consent

Baptist Health, through its nationally accredited Continuing Medical Education Program, maintains compliance with the ACCME's Policy on Clinical Content Validation and the Standards for Integrity and Independence. Additionally, we are responsible for compliance with laws related to copyright/fair use, HIPAA and Protected Health Information. To that end, we are obliged to resolve any conflicts of interest and to review course content prior to the educational course. We request your prompt completion of this attestation form.

If you have questions or changes related to CME management of this symposium, please contact me at 786-596-2398

Speaker Stipend: Baptist Health South Florida will pay you a speaker stipend of $1500 and a travel stipend of $600 for air and ground transportation and meals.  No additional expense reimbursement. 
Hotel Accommodations and Resort Fees: A reservation will be made for you at the Hilton-Miami Dadeland on the evening of Thursday, December 5, 2019, and your confirmation number will be sent to you. Baptist Health will pay for your hotel and resort fees directly for one night. If you wish to extend your stay, additional nights will be at your expense. 
Hotel Parking: Daily parking rates at the hotel will be paid for directly by Baptist Health.

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

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B. Presentation Guidelines: 

Instead of providing a syllabus, Baptist Health CME provides registered attendees with access to speakers’ presentations in PDF format on a limited access webpage before and after the symposium. Access will be shared only with symposium attendees and faculty and will be available until two weeks after the symposium. 

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

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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.

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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.

  1. 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.
  2. 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.
  3. 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".

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

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Please sign your name.
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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