Maryland Long-Term Care Ombudsman Program Form - Department Of Aging Page 3
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
1
2
3Yes_______ No_______
If yes, please explain:
Type of Relationship/Your Role
Facility Name & Location
Start Date – End
Date
If you would like to provide additional information or if there are any other potential conflicts of
interest, please add this below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I acknowledge that this review could adversely affect my acceptance, placement, or participation
within the program. I understand that failure to identify, remedy, and remove a conflict of
interest will result in refusal or termination of my ombudsman designation.
I have read and understand this Conflict of Interest form.
By signature, I am indicating that I provided full disclosure regarding the categories specified on
this form, and acknowledge that I must notify the Maryland Long‐Term Care Ombudsman Program
if my personal circumstances indicate any perceived conflict of interest at this present or in a
future time.
__________________________
__________
(Print name)
(Date)
____________________________
(Signature)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Tlr 1 - Trustline Registry In-home/license Exempt Child Care Provider Program California Department Of Social Services Background Check Application
Legal
Form 1099-ltc - Long-term Care And Accelerated Death Benefits - Department Of The Treasury - 2013
Financial
Form Ccauth - Authorization Form For John Hancock To Accept Credit Card Payments For Long Term Care Insurance
Business
Related Categories
Parent category: Legal