Activities/Relationships Disclosure and Conflicts of Interest Certificate: 2017

 

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Employment Status:

 

 Employment Status


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Disclosure Type:

 

 Disclosure Type


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Contact Information:

 Primary Responsibility: (Select all that apply)

Employee/Contracted Associate
Board Committee Member
Board Member
Physician (MD/DO)
Midlevel/Non-Physician Practitioner (CMS 855-I Definition)
Ensemble RCM LLC
HealthSpan Employee/Contracted Associate
Mercy Health Select (ACO) Participant
Advanced Health Select (CIN) Participant
 

 Location:


(Select one)
 

 First Name:

MI:

 Last Name:

  Title

  Department

 Phone Number

Board and Board Committee Activity:

 

 What Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners Board(s) or Board Committee(s) (collectively the Organization), do you serve on or support? Select all that apply and specify your role within the board/committee e.g., voting or non-voting member, chair, staff, etc. where applicable.

Captive Insurance Company

 Please specify role

Mercy Health-System Board/Board Committees:
Mercy Health-System Board

 Please specify role

Mercy Health-System Foundation Board

 Please specify role

Mercy Health-System Audit & Corporate Responsibility Committee

 Please specify role

Mercy Health-System Executive Committee

 Please specify role

Mercy Health-System Finance & Strategy Committee

 Please specify role

Mercy Health-System Human Resources Committee

 Please specify role

Mercy Health-System Investment Committee

 Please specify role

Mercy Health-System Quality Committee

 Please specify role

Specialty Taskforce or Committee, i.e., Pharmaceutical & Therapeutics

 Please specify role and all that apply

Market Board/Board Committees:
Foundation Board

 Please specify location(s), role and all that apply

Market Board

 Please specify location(s), role and all that apply

Market Executive Committee

 Please specify location(s), role and all that apply

Market Quality Committee

 Please specify location(s), role and all that apply

Market Strategy Development Committee

 Please specify location(s), role and all that apply

Joint Venture Board/Mercy Health and/or Mercy Health Affiliation

 Please specify location(s), role and all that apply

Specialty Taskforce or Committee, i.e., Pharmaceutical & Therapeutics

 Please specify location(s), role and all that apply

Institutional Review Board (IRB) for research

 Please specify locations (s), and internal or external role

Ensemble RCM LLC Board/Committees:
Ensemble RCM LLC Board

 Please specify role

Ensemble RCM LLC Committee(s)

 Please specify committee and role for all that apply

HealthSpan Partners Board/Board Committees:
HealthSpan Partners Board

 Please specify role

HealthSpan Partners Audit & Corporate Responsibility Committee

 Please specify role

HealthSpan Partners Executive Committee

 Please specify role

HealthSpan Partners Human Resources Committee

 Please specify role

Mercy Health Select (ACO) Board/Board Committees:
Mercy Health Select Board

 Please specify role

Mercy Health Select Board Committee(s)

 Please specify role and all that apply

Advanced Health Select (CIN) Board/Board Committees:
Advanced Health Select Board

 Please specify role

Advanced Health Select Board Committee(s)

 Please specify role and all that apply

Other Board/Board Committees:
External Board(s)/Board Committee(s)

 Please specify role and all that apply

None of the above

A. I hereby certify the following:

 

  Pursuant to Mercy Health and/or HealthSpan Partners Board Conflicts of Interest Policy, (the “Policy”) and Core Values in Action, I hereby certify the following:

  1. I have received a copy of the Policy and Core Values in Action and have read and understood them;
  2. I have received education on conflicts management and/or have had any questions answered before completing this disclosure certificate;
  3. I agree to comply with the Policy and the Core Values in Action;
  4. I understand that Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners must report “reportable adverse legal events” to Medicare/Medicaid to maintain enrollment as a Medicare/Medicaid provider;
  5. I understand that Mercy Health, Mercy Health Affiliates (markets) and/or HealthSpan Partners include non-profit organizations and that in order to maintain their federal tax exemption they must engage primarily in activities that are charitable in nature and accomplish one or more of their tax-exempt purpose;
  6. I agree in connection with any and all participation at meetings or business functions to treat all Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners information as confidential and proprietary;
  7. I understand that the definitions of critical terms used in the Disclosure Certificate are the same as defined in the Policy, the Core Values in Action, and the 990 Supplemental Glossary;
  8. I agree to provide all necessary information requested by Management, the Board or Board Committee to determine whether an actual financial interest or conflict of interest exists and, if determined by Management, the Board or Board Committee to be a conflict, I will abstain from deliberation and voting on such matter, and will withdraw from the meeting room during the deliberations and voting on the matter; and
  9. I agree to disclose any potential conflict or any financial interest of me, my family or any business entity related to me or my family, whether previously disclosed by this Disclosure Certificate or any prior Disclosure certificate, any time a matter arises. I will disclose any conflicts of interest that would impact my duties and will withdraw from discussions, making decisions or voting on such matters.

Yes
No

B. Reportable Adverse Legal Event:

 

  Insurers and Medicare/Medicaid regulations require Medicare/Medicaid-participating providers to report any of the following adverse legal events for any board member, official or employee:

  1. Any current involvement as a subject of pending criminal proceedings or investigation.
  2. Any conviction of a Federal or State felony offense, within the last 10 years, determined to be detrimental to the best interests of Medicare/Medicaid and its beneficiaries. Offenses include: (a) crimes against persons; (b) financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes; (c) any felony that placed the Medicare/Medicaid program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct); or (d) any felonies that would result in mandatory exclusion from Medicare/Medicaid.
  3. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or service under Medicare/Medicaid or a State health care program, or (b) the abuse or neglect of a patient in connection with the delivery of a health care item or service.
  4. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item or service.
  5. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any investigation into any health care criminal offense.
  6. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
  7. Any revocation or suspension of a license to provide health care by any State licensing authority, including the surrender of a license while formal disciplinary proceedings were pending before a licensing authority.
  8. Any revocation or suspension of accreditation.
  9. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program, or any debarment from participation in any Federal Executive Branch procurement or non-procurement program.
  10. Any current Medicare/Medicaid payment suspension under any Medicare/Medicaid billing number.
  11. Any Medicare/Medicaid revocation of any Medicare/Medicaid billing number.

Yes, I report the following Adverse Legal Event - OR -
No, I have no Reportable Adverse Legal Events.

C. Other Activity/Relationships:

 

New federal and state Sunshine Laws require greater transparency and disclosure of activities and relationships. Please disclose any activities and relationships that apply.

 

Have you participated, directly or indirectly, with Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners (collectively the Organization) in any of the following activities/relationships?

 

  C.1 Contracts(s) or service arrangement(s) for employment, professional or purchased services, medical directorship, on-call and/or lease.

Yes
No
 

  C.2 Joint Ventures with the Organization or outside direct or indirect entities/organizations/persons that provide health care items or services.

Yes
No
 

  C.3 Research, Clinical Research or Human Subject Research sponsored by external grant monies.

Yes
No
 

  C.4 Consulting Engagements or Advisory Board Engagements with external healthcare-related industries (i.e., pharmaceuticals, device manufacturing, informatics, distribution companies, etc.).

Yes
No
 

  C.5 Vendor Sponsored Activities/Relationships (i.e., consulting fees, faculty or speaking fees, travel, lodging, entertainment, gifts, meals/food, including vendor paid expenses related to product education/training received off site, etc.).

Yes
No

D. After reviewing the Policy and the Core Values in Action:

 

I hereby certify that I am making the following disclosures regarding Financial Interests, Business Transactions, Other Potential Conflicts of Interest, Reportable Family Relationships or reportable Gifts and Gratuities of any kind.

 

D.1 Financial Interests/Business Transactions

  List all financial interests and business transactions of you, your family member(s) or any business entity related to you or your family where the Organization has or is negotiating an arrangement or transaction, either currently or within the past five (5) years. For each arrangement, business transaction or financial interest listed, check the blocks that indicate its annual value, nature and disclose the relationship of the party holding the financial interest or business transaction. NOTE: A reportable financial interest does not exist related to widely held securities if all three parts of the test are met. See the discussion under the definition of “financial interests” in the Policy.

Yes, I have the following Financial Interests and Business Transactions to report: - OR -
No, I have no Financial Interests or Business Transactions to report.
 

D.2 Other Potential Conflicts of Interests

  Identify all non-Mercy Health, non-Ensemble RCM LLC or non-HealthSpan Partners organizations or businesses of which you are a board member, director, officer, trustee, agent or employee in which you, your family member(s) or a business entity related to you or your family have an interest which may compete or otherwise may be in conflict with the Organization. For each arrangement, business transaction or financial interest listed, check the blocks that indicate its annual value, nature and disclose the relationship of the party holding the financial interest or business transaction.

Yes, I have the following Interests to report: - OR -
No, I have no other potential Conflicts of Interest.
 

D.3 Reportable Family Relationships

  Identify all family relationship(s) which you have with a board member, director, officer, trustee, agent, employee, or vendor of the Organization.

Yes, I have the following Reportable Family Relationships to report: - OR -
No, I have no Reportable Family Relationship Interest.
 

D.4 Gifts and Gratuities

  List any gifts, gratuities, or entertainment received by you, your family or a business entity related to you or your family since your last annual disclosure report that might reasonably be perceived as being given to you, your family or to a related entity due to your relationship to the Organization. Best practice is to report all gifts received. Gifts totaling $100 to $300 from a single vendor need to be reported. Effective January 1, 2008, cumulative gifts >$300 must be declined if from a current or prospective Organization vendor. Physicians are subject to stricter Federal Stark Laws and non-Monetary and Incidental Benefit reporting requirements for gifts and gratuities that may supersede and may replace some of the Conflicts of Interest Policy Gifts and Gratuities provisions. Click here to review the Conflicts of Interest Policy and the Core Values in Action Booklet, for the definition of gifts and gratuities.

Yes, I report the following Gifts/Gratuities: - OR -
No, I have received no Reportable Gifts/Gratuities.

E. Loans:

 

  Loans include salary advances or other advances and receivables. Have you received or made a loan (including salary advances or other advances and receivables) to or from a Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners (collectively the Organization)?

Yes, I report the following Organizational Loans - OR -
No, I have not received or made an Organizational Loan.
 

  E.1 I have received a loan from the Organization:

Yes
No
 

  E.2 I have made a loan to the Organization:

Yes
No

F. Grants and Other Assistance:

 

  F.1 At any time during the prior taxable year (from January 1 to December 31), did you or a family member (as defined in the glossary) receive any grants or other assistance (including provisions of goods, services, or use of facilities) from the Mercy Health, Mercy Health Affiliates (markets), Ensemble RCM LLC and/or HealthSpan Partners (collectively the Organization)? Examples of grants are scholarships, fellowships, internships, prizes, and awards. A grant includes the gift portion of part-sale, part-gift transaction.

Yes, I or a family member received Grants or Other Assistance from the organization as follows: - OR -
No, I or a family member have not received Grants or Other Assistance from the organization.
 

  F.2 At any time during the prior taxable year did an entity in which you had ownership interest do business with the Organization and receive any grants or other assistance from the Organization?

Yes, an entity in which I have Ownership Interest has received Grants or Other Assistance from the Organization as follows:
        – OR -
No, entities in which I have an Ownership Interest have not received Grants or Other Assistance from the Organization.

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