Disclosure of Relevant Financial Relationships & Commitment to Valid Content
As a provider accredited by the Medical Society of the State of New York (MSSNY), the Rochester Academy of Medicine must insure balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Any individual being considered to participate in an activity who is in a position to control the content is required to disclose any relevant financial relationships.

NOTE: ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. ACCME considers relationships of the person involved in the CME to include financial relationships of a spouse or partner. All commercial relationships that create a conflict with the faculty’s control of content must be resolved before the educational activity occurs.

1. ACCME guidelines state that all individuals who are in a position to control content of the CME activity are to disclose all of their commercial relationships. Those who are in a position to control include the course director, speakers, case presenters, planning committee members, expert panelists and anyone else who is expected to take an active role in the education.

2. All Activity Directors and Planning Committee members must complete Disclosure of Relevant Financial Relationship forms BEFORE planning begins.

3. Failure to disclose conflicts of interest in a timely manner may result in recusal from the activity.


When do relationships create ‘conflict of interest’?

The ACCME considers financial relationship to create actual conflicts of interest in CME when individuals have both a financial relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that commercial interest.


Where is the ‘conflict’?

When the provider’s interests are aligned with those of a commercial interest the interests of the provider are in conflict with the interests of the public. The interests of the people controlling CME must always be aligned with what is in the best interests of the public.


How do these circumstances create a conflict of interest?

The potential for increasing the value of the financial relationship with the commercial interest creates an incentive to influence the content of the CME – an incentive to insert commercial bias. Commercial bias is prohibited in CME.

First & Last Name
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Your Email Address
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Your Phone Number
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CME Activity Title
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Presentation Title
Only required for speakers for Single Live Events.
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CME Activity Date
If you are completing this form for an RSS please put the first date of the accreditation cycle.
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Additional Activity Dates
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Indicate your Role in this CME Activity
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Have you (or spouse/partner) had a personal financial relationship in the last 12 months with the manufacturer of the products or services that will be presented in this CME activity (planner) or in your presentation (speaker/author)?
Please provide the name of the commercial interest and the type of relationship you or your spouse has with the commercial interest.
Relationships can include: stock ownership, employment affiliation, royalities, patents, speakers bureau member, consultant or advisor for the commercial interest.
Your answer
Commitment to Valid Content
Have you ever been excluded, debarred, suspended or deemed ineligible to participant in federal health care programs or in federal procurement or non-procurement programs or been convicted of a criminal offense that would result in mandatory exclusion from such programs or debarred or excluded by another federal agency?
In the last two years, have you violated or received notice of any violation or potential violations related to ACCME/MSSNY or other continuing medical education policies and standards?
I understand that the information presented to the learner must be unbiased, scientifically balanced and based on best available evidence and best practices in medicine. I agree that all scientific and clinical research referred to, reported or used in CME to justify patient care recommendations will conform to the generally accepted standards of experimental design, data collection and analysis.
I agree to provide my presentation, reference and handouts to the Rochester Academy of Medicine prior to my presentation. I understand that participants may evaluate my CME presentation.
I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of this CME activity. In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996. (HIPAA)
I agree to provide a balanced presentation that is free from commercial bias or financial interest for or against any commercial product or service. I agree to avoid the use of trade names in my presentation. If I determine that it is important to clarify via the use of trade names from all available companies will be included.
Electronic Signature
The undersigned hereby agrees to use an electronic signature in lieu of a paper-based signature, understanding that electronic signatures are legally binding in the United States and in other countries.

I Hereby Certify That:

1. This disclosure and commitment form was completed accurately, and I attest to the validity of the information contained within.

2. I agree to collaborate with the Rochester Academy of Medicine CME Coordinator to ensure that the necessary follow-up is consistent with the MSSNY and ACCME Essential Areas, Elements, Criteria, Policies, and Standards for Commercial Support (SCS).

First & Last Name
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Professional Title
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License #
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