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CONFLICT OF INTEREST ATTESTATION Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement PIHPs must comply with federal regulations to obtain, maintain, disclose, and

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How to fill out conflict of interest attestation

01

Read the conflict of interest policy to understand the expectations and guidelines.

02

Fill out the personal information section with your name, position, and department.

03

Disclose any financial interests or relationships that may pose a conflict of interest.

04

Sign and date the attestation to confirm that all information provided is accurate and complete.

Who needs conflict of interest attestation?

01

Employees, board members, and anyone else who is in a position of influence or decision-making within the organization may need to fill out a conflict of interest attestation.

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What is conflict of interest attestation?

Conflict of interest attestation is a formal declaration or statement made by an individual regarding any potential conflicts of interest that may arise in their professional or personal life.

Who is required to file conflict of interest attestation?

Those individuals who are in positions of power, influence, or decision-making within an organization or government agency are typically required to file conflict of interest attestation.

How to fill out conflict of interest attestation?

Conflict of interest attestation forms are usually provided by the organization or agency requiring the disclosure. The individual must truthfully disclose any potential conflicts of interest they may have.

What is the purpose of conflict of interest attestation?

The purpose of conflict of interest attestation is to promote transparency, integrity, and ethical behavior within an organization or government agency by identifying and addressing any potential conflicts of interest.

What information must be reported on conflict of interest attestation?

The individual must typically report any financial interests, relationships, or other factors that may influence their decision-making or create a conflict of interest.

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