2023 FamMed Forum Disclosure Form

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


Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). 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 contact Shannon Cook at scook@lutinemanagement.com

(Contact number for day of activity)

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).

Select or enter value
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Definition of an Ineligible Company:

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.


(For specific examples of ineligible companies visit accme.org/standards.)

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

Nature of Financial Relationship:

Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. 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?
2. Has Relationship Ended?
3. Has the Relationship Ended?
4. Has Relationship Ended?
5. Has Relationship Ended?
6. Has Relationship Ended?
7. Has Relationship Ended?
8. Has Relationship Ended?
9. Has Relationship Ended?
10. Has Relationship Ended?

Please describe any additional financial relationships, of any amount with an ineligible company with In the past 24 months below.

I attest that the above information is correct as of this date of submission.


Please check for signature.

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

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