2025 Disclosure Form

To be Completed by Planner, Faculty, or Others Who May Control Educational Content:


As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, utilized by most accrediting bodies to ensure educational content is free from commercial bias, please 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. If you have questions, please reach out to Mandy Komenko at mkomenko@lutinemanagement.com.


Individuals who refuse to provide this information will be disqualified from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.

 
 
 
 
 

Please choose the name of the organization planning/holding the meeting from the below list.

 

Please select the title of the educational meeting or activity in which you are participating. If you do not see the activity listed below, please select the "Other" category and enter the title.

 

Individual's prospective role(s) in education:


Identify the prospective role(s) that you have in the planning and delivery of this education (choose all that apply).

 

In the past 24 months, have you had a financial relationship of any amount with an ineligible company?


Definition of an Ineligible Company: Companies that are ineligible to be accredited in the ACCME System (ineligible companies) are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Examples of such organizations include:

  • Advertising, marketing, or communication firms whose clients are ineligible companies
  • Bio-medical startups that have begun a governmental regulatory approval process
  • Compounding pharmacies that manufacture proprietary compounds
  • Device manufacturers or distributors
  • Diagnostic labs that sell proprietary products
  • Growers, distributors, manufacturers or sellers of medical foods and dietary supplements
  • Manufacturers of health-related wearable products
  • Pharmaceutical companies or distributors
  • Pharmacy benefit managers
  • Reagent manufacturers or sellers
 

Typing my name in the space below, I attest that I have read and completed this form myself and have provided current and accurate information to the best of my ability. I am aware that financial disclosure information provided on this form will be shared with learners prior to their engagement in this CME activity.