Narbha Peer Review Committee Sign-In Sheet Page 2
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2NARBHA PM Form 10.21.3
NARBHA PEER REVIEW COMMITTEE
CONFIDENTIALITY AND CONFLICT OF INTEREST AGREEMENT
Northern Arizona Regional Behavioral Health Authority Peer Review includes the reviewing of
information that contain behavioral health recipient identifying information, provider identifying
information and other information deemed confidential pursuant to A.R.S. Title 36, Chapter 25, Article 1.
I therefore agree to:
1.
Only disclose behavioral health recipient identifying and provider identifying information within
the Peer Review Committee structure;
2.
Use any information obtained ONLY for carrying out the peer review described below;
3.
Not discuss or disclose any information obtained through peer review to any person not on the Peer
Review Committee;
4.
Return all records/information provided to me for this purpose and destroy any copies or notes I
have made; and
5.
Provide a certificate of destruction to the Committee when requested attesting that all
records/information provided to me any copies have been destroyed.
The purpose of the Peer Review Process is to contribute to the efficacy of NARBHA delivery system
through:
.
1
An organized process of assessment, by professional peers, of the quality and appropriateness of
the practices employed by providers; and
2.
The effective application of quality improvement opportunities so that the quality and
appropriateness of services is continuously improved.
I understand that I have a responsibility and an obligation to notify the NARBHA Chief Medical Officer
or designee if a potential conflict of interest of fact or appearance exists, because I am:
•
The provider who is under review;
•
A provider affiliated with the practice of the provider under review;
•
A relative (pursuant to A.R.S.§ 38-502) of the provider under review;
•
A personal associate of the provider under review;
•
In a financial relationship with the provider under review;
•
Affiliated with a competitor of the provider under review;
•
An employee of the facility where the matter under review took place; or
•
Aware of any other reason that is a potential conflict of interest.
The review process is being conducted pursuant to the NARBHA Policy Manual Peer Review Process,
which requires review and evaluation of providers’ professional actions related behavioral health service
recipients, by a selected peer group.
Confidential Quality Assurance Document Protected by A.R.S. 36-2401 through 2404, A.R.S. 36-2917,
42 U.S.C . 1320c, 42 U.S.C. 11101-11152
PM Form 10.21.3-Sign In Sheet-Confidentiality/Conflict of Interest Agreement
Effective: 04/11/14
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