2009 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 in 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.
SUBMITTING ELECTRONICALLY - Must be received by January 31, 2009
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 type name will be acceptable as your signature. Save the completed form to your personal files and e-mail the completed form back to Kelli.Reischl@alegent.org. Completed forms submitted electronically must originate from your own e-mail address.
SUBMITTED BY MAIL - Must be received by January 31, 2009
You may return your completed Conflicts of Interest Annual Disclosure Statement by mail. Return your signed, completed form to Kelli Reischl, Alegent Health, McAuley Center, 12809 W Dodge Road, Omaha, NE 68154.
2009 CONFLICT OF INTEREST STATEMENT
Alegent Health Officers, Directors and Committee Members
Outside Concerns
1) Do You or a Family Member hold any positions whether as a director, employee, consultant or other capacity, in any outside concern from which you have reason to believe that System and/or Corporation now makes purchases, obtains services (including the services of buying or selling stocks, bonds or other securities) or with who it has had a previous or ongoing discussions concerning a potential transaction or arrangement, including, but not limited to, lease arrangements or shared facility, employee, or equipment arrangements)?
Yes No
If yes, please provide a brief description of such positions or material Financial Interests held in the space below.
Control Interests in the System
2) Do You or a Family Member own, directly or indirectly, through business, investment or family, in whole or in part any interest in any mortgage, deed of trust, note or other obligation which is secured in whole or in part by the System and/or Corporation or any institutions affiliated with the System, or any assets of the institutions affiliated with the System and/or Corporation?
Yes No
If yes, please provide a brief description of such mortgage, deed of trust, note or obligation in the space below.
Other Providers
3) Are You or a Family Member an employee, officer, director, consultant to or partner of any other Provider?
Yes No
If yes, please list in the space below the name(s) of the other Provider(s) and the position(s) you or Family Member hold.
4) Do You or a Family Member own directly or indirectly, through business, investment or family, any capital stock, profits, or interest in any other Provider?
Yes No
5) Do You or a Family Member own directly or indirectly, through business, investment or family, any capital, stock, profits, or other interest in any entity which in turn owns capital, stock, profits, or interest in any other Provider?
Yes No
6) Do You or a Family Member own in whole or in part any interest in any mortgage, deed of trust, note or other obligation which is secured in whole or in part by any other Provider or its assets?
Yes No
7) If You or a Family Member are now or contemplate being engaged in activities or circumstances not referred to in your prior answers, from which a potential Conflicts of Interest Transaction or Financial Interest might occur, please list and briefly describe those activities or circumstances below.
None Explanation
Disqualified Person
8) As defined in Policy 000.053, Section II.H, are you a Disqualified Person?
Yes No
If Yes, which subsection of Policy 000.053 Section II.H defines your circumstances?
General
9) Many other circumstances which could not possibly be listed here could give rise to a potential Conflicts of Interest Transaction. These would include any instances where the actions or activities of any individual on behalf of the System and/or Corporation also involve the obtaining of an improper gain or advantage, or an adverse effect on the System's and/or Corporation's interests. For example, to accept gifts, excessive entertainment, or other favors from any outside concern that does, or is seeking to do, business with, or is a competitor of the System and/or Corporation, or who could otherwise profit from information available to an Officer, Director, or Committee Member of the System and/or Corporation under certain circumstances might give rise to a claim that such action was intended to influence or possibly would influence an individual in the performance of his or her duties. This does not include the acceptance of items of nominal or minor value (less than $100 annually) that are clearly tokens of respect or friendship and not related to any particular transaction or activity of the System and/or Corporation. Also, to disclose or use information relating to the System's and/or Corporation's business for the personal profit or advantage of an individual or his or her immediate family would constitute a Conflicts of Interest Transaction. Full disclosure of any such situation or any other circumstances in doubt at this time and as it should occur in the future should be made to avoid any possible appearance of conflict and permit an impartial and objective review of the circumstances.
Please list any Potential Conflicts of Interest Transactions:
UNDERSTANDING OF COMPLIANCE
The undersigned acknowledges that he/she (a) understands that the Conflicts of Interest Policy in the Corporation Bylaws applies to all Officer, Directors and Members of a Committee or Subcommittee of the System and/or Corporation, (b) has received a copy of the Conflicts of Interest Policy, (c) has read and understands the policy, (d) agrees to comply with the policy, and (e) understands that the System and/or Corporation 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.
The undersigned further acknowledges that he/she is 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 states that he/she has no knowledge of any activities, actions, or inactions by him/her 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 Officer, Director or Committee Member of the System and/or Corporation is required. This information is made available to you as an Officer, Director or Committee Member of the System and/or Corporation for that purpose alone and any such information is not to be shared with outside sources without the written consent of the Chair. By signing below you have indicated your understanding of this requirement and the confidential nature of the information.
Print Name _________________________________ Email Address___________________________________
Signature ___________________________________ Date___________________________________________
