Maryland Long-Term Care Ombudsman Program Form - Department Of Aging

Download a blank fillable Maryland Long-Term Care Ombudsman Program Form - Department Of Aging in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Maryland Long-Term Care Ombudsman Program Form - Department Of Aging with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

 
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 
1
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 
1
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.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3