[COMPANY NAME]
Stark Law Compliance Checklist
Fair Market Value Arrangement Exception
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Name of the Agreement: |
_____________________________ |
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Other Party(ies) to the Agreement: |
_____________________________ and ____________________________ |
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Effective Date: |
_____________________________ |
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Termination Date: |
_____________________________ |
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Other Contracts with this Party(ies): |
____________________________ |
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Name of the Agreement(s):_____________________________ Party(ies) to the Agreement: _____________________________and _____________________________ Effective Date:_____________________________ Termination Date:___________________________ | |
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Meets Stark Fair Market Value (FMV) Exception (circle): |
Yes or No |
______________________________ __________________
INITIAL REVIEWER DATE
______________________________ __________________
FINAL REVIEWER DATE
Stark Law Compliance Checklist
Fair Market Value Arrangement Exception