This customizable document, Conflict of Interest Disclosure Form, is taken from MCN Healthcare’s Home Care Corporate Compliance Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN’s templates save you time, money and resources, rather than developing healthcare policy and procedure manuals from scratch.

Here is some sample content from Conflict of Interest Disclosure Form:

	CONFLICT OF INTEREST DISCLOSURE Please check the applicable paragraph and complete this statement as appropriate. I hereby affirm that I know of no issues that would present a conflict of interest arising from any situation related to my involvement/association with . I may have a conflict of interest arising from the following situation: Describe the potential conflict, including both the other entity in which you have an interest and the dealings it has with and the appropriate dates the conflict arose. I understand that the Conflict of Interest Policy prohibits my involvement in...
Second excerpt:
	...understand that the Conflict of Interest Policy prohibits my involvement in transactions in which I have a conflict. Therefore, in any instance in which I may be required to participate in a decision affected by such conflict, I will notify the Administrator/Chief Executive Officer of the conflict of interest and will abide by the resultant decision. Name: Signature: Reference...