CONFLICT OF INTEREST REVIEW
All long‐term care ombudsman representatives must disclose any current, past, or any potential
conflicts of interest that may require review by the Maryland Long‐Term Care Ombudsman
Program. Please carefully respond to the following questions in regards to yourself and
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immediate family members.
1) Statement of Business Relationships with Long‐Term Care Providers
Have you or an immediate family member had a business relationship with a long‐term care
provider including current or past employment?
Yes_______ No_______
If yes, please explain:
Type of Relationship/Your Role
Provider(s) Name & Location
Start Date – End
Date
2) Statement of Investment Relationship with Long‐Term Care Providers
Have you or an immediate family member had funds invested with investment companies or
corporations that have a financial interest in one or more long‐term care facilities? Do you have
current investments? Mutual funds that include divested interest in a portfolio do not have to
be listed.
Yes_______ No_______
If yes, please explain:
Type of Relationship/Your
Investment Company/Corporation Name
Dates
Role
and Facility
3) Statement of Personal Relationship with Long‐Term Care Providers
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Immediate family, pertaining to conflicts of interest as used in section 712 of the Older Americans Act
(OAA), means a member of the household or a relative with whom there is a close personal or significant
financial relationship.