Disclosure of Significant Affiliations

Disclosure of Significant Affiliations & Potential Conflicts of Interest

Please complete the form below to indicate any possible significant affiliations or conflicts of interest.
I am completing this Disclosure of Significant Affiliations & Potential Conflicts of Interest due to my board, committee or task force involvement with:
Alternatively, download this PDF document, sign it, and return to foundation@wismed.org.
Name

First NameLast NameCredentials
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone & Fax

Rows	Telephone Number	Fax Number
Home
Clinic
Office
Cell
Nurse/Assistant

Preferred Email Address
example@example.com
Alternate Email Address
example@example.com
Alternate Email Address
example@example.com
If applicable, please list your board certification(s) and include the name of the board that issued the certification(s) and the date(s) on which it issued the certification.
List all relationships that you currently hold and have held during the preceding five (5) years with entities including hospitals, hospital systems, clinics, managed care organizations, ambulatory health care facilities and teaching facilities (including academic appointments). Identify the name, location and nature of your position and dates that you held that position.
List all leadership relationships that you, your spouse/partner, parent(s) and child(ren) currently hold and have held during the preceding five (5) years in an organization. Leadership relationships include service as an officer, director or trustee of an organization, including but not limited to clinics, hospitals, ambulatory care centers, nursing homes, pharmaceutical companies, device manufacturers, managed care organizations, insurance companies and other health care related entities. Identify the name, location and nature of your position and dates that you held that position. Example: Spouse / Company "X" / Director / 1-1-09 - Present
List all financial relationships that you, your spouse/partner, parent(s) and child(ren)currently hold or have held during the preceding five (5) years with any relevant commercial or governmental interest, including but not limited to insurance companies, medical liability insurers, device manufacturers, pharmaceutical companies, managed care organizations and government health care programs. Financial relationships include salary, intellectual property rights, consulting fees, contracts, honoraria, stock ownership representing more than ten(10) percent of any one corporation’s holdings, stock options, in-kind gifts or contributions or any other financial benefit. Identify what was received, who received it and the role for which it was received. Example: Self / Company "X" / Honorarium / Speaker
List all affiliations that you currently hold and have held during the preceding five(5) years with federal, state and local governmental agencies, boards, committees and task forces, including but not limited to the Medical Examining Board, Injured Patients and Families Compensation Fund, Worker’s Compensation Committee and National Institute of Health Committee.
List all professional society memberships, including state, county and or national medical societies.
List all medical specialties in which you have practiced.
Do you intend to practice an additional specialty or specialties in the near future that are not listed in the above answer? If yes, please describe the additional specialty.
Conflict of Interest Policy agreement

I have received a copy of the Wisconsin Medical Society's Conflict of Interest Policy and Procedure(Policy). I read and understand the Policy and agree to comply with it by disclosing significant affiliations and conflicts of interest that exist or may arise in the future. I affirm that the information in this disclosure document is accurate and complete to the best of my knowledge. I understand that I have a continuing obligation to comply with the Policy and to update the information provided on this disclosure form, if my circumstances or relationships change. I will promptly disclose any affiliations, actual conflicts and potential conflicts of interest as required by the Policy. I understand that the Wisconsin Medical Society will provide the information that I disclose on this form to Trustees or others deemed necessary upon request.

Disclosure of Significant Affiliations & Potential Conflicts of Interest

Additional Information