Joint Providership Application Disclosure Form 

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Please list the course name.
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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: 
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C. 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.

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

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Select one.

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