Pomona Valley Hospital Medical Center in California uses this checklist to ask vendors to disclose any relationship they may have that could create a conflict of interest with an ordering provider or any employee. Contact Compliance Officer Kathy Perkins at kathy.perkins@pvhmc.org.
Conflict of Interest
“Company/vendor” means a product manufacturer, distributor or service provider for healthcare product and services.
“Family relative” means the following individuals: husband or wife; birth or adoptive parent; child or sibling; stepparent, stepchild, stepbrother or stepsister; father-in-law, son-in-law, daughter-in-law or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild.
|
# |
Category |
Requirements |
COMMENTS & EXPLANATION |
Vendor agrees | |
|---|---|---|---|---|---|
|
Y |
N | ||||
|
F.1 |
Company |
Does your company have a current business relationship with PVHMC? Please identify those supplies/services or equipment. | |||
|
F.2 |
Ownership |
Does your company, in whole or part, directly or indirectly, own any part of a company or division that currently has a business contract with PVHMC? (not mentioned above) | |||
|
F.3 |
Involvement |
Is your company, or any affiliated company, involved with any other matter that could be perceived as a conflict of interest with PVHMC? | |||
|
F.4 |
Compensation |
What is the approximate compensation paid by PVHMC to the companies listed in F.1, F.2 or F.3? | |||
|
F.5 |
Family relationships |
Does any member of your company have a family relative who works at PVHMC? Please provide name and title of both your employee and ours, and their relationship. | |||
|
F.6 |
Stock |
Does your company own stock in any publicly traded healthcare-related company (e.g., medical manufacturer, pharmaceutical company, laboratory company)? | |||
Please provide this information to help ensure our compliance with the new regulatory requirement. I represent that the answers provided herein are truthful and accurate as of the date of my signature below. I agree to immediately notify Pomona Valley Hospital Medical Center of any changes in the above disclosed information.
Name: _____________________________________________________
Title: ______________________________________________________
Signature: __________________________________________________
Date: ______________________________________________________
