NMMRA: New Mexico Medical Review Association
New Mexico's Health Quality Improvement Organization

Faculty Disclosure Declaration (Form F)

Name:
E-mail:

Faculty member/author/teacher:
CME activity title:
Date of activity:
Location:
City:
Identified need for this activity:
Expected result:
Purpose or objective:
Summary of content:

The New Mexico Medical Review Association (NMMRA) is accredited by the New Mexico Medical Society (NMMS), which is recognized by the Accreditation Council for Continuing Medical Education (ACCME). As such, we have made the choice to meet the ACCME's expectations for our practice of continuing medical education. Our accreditation is important to us. We look forward to working together to provide CME at the highest standard. Please disclose all relevant financial relationships with any commercial interest (see below for definitions). Should it be determined that a conflict of interest exists as a result of a financial relationship you may have, this will need to be resolved prior to the activity. If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this CME activity.

First, list the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.

Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). NMMRA does NOT want to know how much you received.

Third, describe your role.

Commercial Interest Nature of Relevant Financial Relationship
(Include all those that apply)
What I Received My Role