2024 INMED Disclosure Form

Disclosure of Relevant Financial Relationships

By Planners and Presenters of Continuing Medical Education Activities
Updated January 2025

Dear Prospective Planner/Presenter:
We look forward to the opportunity to include you as a planner or presenter in Continuing Medical Education.

Why am I receiving this communication?
Institute for International Medicine (INMED) is accredited by the Kentucky Medical Association. We appreciate your help in partnering with us to follow accreditation guidelines and help us create high-quality education that is independent of industry influence. In order to participate as a person who will be able to control the educational content of this accredited CE activity, we ask that you disclose all financial relationships with any ineligible companies that you have had over the past 24 months. We define ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; you must disclose all financial relationships, regardless of
the amount, with ineligible companies. We ask you to disclose regardless of whether you view the financial relationships as relevant to the education.For more information on the Standards for Integrity and Independence in Accredited Continuing Medical Education, please visit accme.org/standards.

Why do we collect this information?
Since healthcare professionals serve as the trusted authorities when advising patients, they must protect their learning environment from industry influence to ensure they remain true to their ethical commitments. Many healthcare professionals have financial relationships with ineligible companies. By identifying and mitigating relevant financial relationships, we work together to create a protected space to learn, teach, and engage in scientific discourse free from influence from organizations that may have an incentive to insert commercial bias into education.

What are the next steps in this process?
After we receive your disclosure information, we will review it to determine whether your financial relationships are relevant to the education. Please note: the identification of relevant financial relationships does not necessarily mean that you are unable to participate in the planning and implementation of this educational activity. Rather, the accreditation standards require that relevant financial relationships are mitigated before you assume your role in this activity.

If you have questions about these expectations, please contact us at CME@inmed.us

Personal Information
Full Name*

First NameLast Name
E-mail*
example@example.com
Credentials*
Place N/A if no credentials are available

Activity Information
Organization hosting the activity/Joint-Provider:*
If you participate in various activities with multiple joint-providers, please select all that apply.
Activity Name:*
If you participate in multiple activities you can note ''multiple activities''
Date of Activity (or date of first activity for the year)*

MonthDayYear

Planners
ELECTRONIC SIGNATURE: By entering my name, I am electronically signing this agreement, attesting that the above information is correct as of the date of submission.*

First NameLast Name
Please upload your CV, resume, or professional/academic bio.*

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Provide a photo (head shot) if you are speaking at a symposium or annual conference. Not needed for grand rounds, journal club, or case conference activities.

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Please provide a 50 word bio if you are speaking at a symposium or annual conference. Not needed for grand rounds, journal club, or case conference activities.

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Should be Empty:

	Enter the name of the Ineligible Company An ineligible company is an entity whose primary business is producing, marketing, selling, re-selling or distributing healthcare products used by or on patients. For definition and examples of ineligible companies visit: https://accme.org/faq/what-accmes-definition-ineligible-company	Enter the nature of the Financial Relationship In addition to the above examples, Individual Stocks and Stock Options should be disclosed; Diversified Mutual Funds do not need to be disclosed. Research Funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the funds.	Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please check the box in this column. This will help determine if any mitigation steps need to be taken.
Name of ineligible company
Name of ineligible company
Name of ineligible company

	Enter the name of the Ineligible Company	Enter the nature of the Financial Relationship	Check if the relationship has ended
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company
Name of ineligible company

	Agree	Disagree
I will ensure that all recommendations for patient care are based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.
I will ensure that alll scientific research referred to, reported, or used in support or justification of a patient care recommendation conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.
I will ensure that any discussion, debate, and/or exploration of new and evolving topics are clearly identified as such within the program and individual presentations and that any engagement with these topics will occur without advocation for, or promotion of, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.
I will ensure that the activity will exclude any advocacy for, or promotion of, unscientific approaches to diagnosis or therapy, or recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.
I will ensure that any speakers I suggest and/or content I teach is independent of commercial bias.
I will recuse myself from planning activity content in which I have a conflict of interest with an ineligible company.
I will ensure that education is fair and balanced and that any content presented supports safe, effective, patient care.
I will not actively promote or sell products or services that serve my professional or financial interests.

Disclosure of Relevant Financial Relationships

Personal Information

Activity Information

Disclosures

Attest to the Following:

Planners