2010 CONFLICT OF INTEREST STATEMENT -
For Alegent Health Officers, Directors and Committee Members
CONFLICTS OF INTEREST
Pursuant to Article 12 of the Alegent Health Bylaws, the purpose of Alegent Health's Conflicts of Interest Policy ("Policy") (000.053) is to protect its interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an Officer, Director or Committee Member of the System or Corporation. This questionnaire is submitted in order to obtain information necessary for compliance with the Policy, and the federal disclosure requirements of the System under the Medicare and Medicaid programs.
As an Officer, Director or Committee Member Person, you are required to read, understand and comply with the Policy and associated policies. If you have questions regarding the Policy, please contact Charles V. Sederstrom, General Counsel (402-343-4425). All terms used in this questionnaire have been defined in the Policy.
It is important to remember in answering this questionnaire that an affirmative answer should be given if an affirmative response is appropriate to either you or to any of your Family Members.
Please respond to all of Questions 1 through 9 by clicking on the appropriate box and/or providing documentation in the gray expandable field. FORM
SUBMITTING ELECTRONICALLY - Must be received by January 31, 2010
You may return your Conflicts of Interest Annual Disclosure Statement electronically by typing your full legal name in the Print Name and signature fields, the current date and your e-mail address. When returned by electronic mail, your typed name will be acceptable as your signature. Save the completed form to your personal files and e-mail the completed form back to Maureen.Cavanaugh@alegent.org. Completed forms submitted electronically must originate from your own e-mail address.
SUBMITTED BY MAIL - Must be received by January 31, 2010
You may return your completed Conflicts of Interest Annual Disclosure Statement by mail. Return your signed, completed form to Maureen A. Cavanaugh, Alegent Health, McAuley Center, 12809 W Dodge Road, Omaha, NE 68154.
2010 CONFLICTS OF INTEREST DISCLOSURE STATEMENT
I hereby certify that either I or one or more of my family members have the following interests in the following organizations with which Alegent has, or might reasonably in the future enter into, a relationship or a transaction:
|Name of Organization
||Person with Interest
||Description of Interest
"Conflicting Interest" shall mean service as a member, shareholder, trustee, director, officer or employee of any organization or governmental entity that either competes with Alegent or is involved or is likely to become involved in any litigation or adversarial proceeding with Alegent. "Conflicting Interest" may also include when you or a family member is involved or is likely to be involved in any litigation or adversarial proceeding with Alegent Health.
"Financial Interest" shall mean any arrangement or transaction pursuant to which you have, directly or indirectly, through business, investment or family, either: (1) a present or potential ownership, investment interest or compensation arrangement in any entity with which Alegent has or may have a transaction or arrangement; or (2) a compensation arrangement with Alegent.
UNDERSTANDING OF COMPLIANCE
I acknowledge that I (a) understand that the Conflicts of Interest Policy (000.046) applies to all Interested Persons of the System, (b) it has been determined that I am an interested person, (c) I have received a copy of the Conflicts of Interest Policy, (d) I have read and understand the policy, (e) I agree to comply with the policy, and (f) I understand that the System is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities that accomplish one or more of its tax-exempt purposes.
I further acknowledges that I am familiar with the Alegent Health Standards of Conduct (300.004) and Reporting on Issues Related to Corporate Integrity (300.042) policies, copies of which are electronically attached, and state that I have no knowledge of any activities, actions, or inactions by myself or anyone else that would constitute a violation of the Alegent Health Standards of Conduct Policy or any federal, state, or local law, regulation or statute.
UNDERSTANDING OF CONFIDENTIALITY
The strictest confidentiality of information obtained by means of your service as an Interested Person of the System is required. This information is made available to you as an Interested Person of the System for that purpose alone and any such information is not to be shared with outside sources without the written consent of the CEO. By signing below you have indicated your understanding of this requirement and the confidential nature of the information.
SUBMITTING ELECTRONICALLY - MUST BE RETURNED BY March 22, 2010
You may return your Conflicts of Interest Annual Statement electronically by typing your full legal name in the Print Name and Signature fields, the current date, and your e-mail address. When returned by electronic mail, your typed name will be accepted as your signature. Save the completed form to your personal files and e-mail the completed form back to Maureen.Cavanaugh@alegent.org. Completed forms submitted electronically need to originate from your personal email address.
SUBMITTING BY MAIL - MUST BE RETURNED BY March 22, 2010
You may return your completed Conflicts of Interest Annual Statement by mail. Return your signed, completed form to Maureen Cavanaugh, Alegent Health, McAuley Center, 12809 W Dodge Road, Omaha, NE 68154.
Print Name _____________________________________________________