Name *

First Name

Last Name

Phone *

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I attest that the above information is correct as of this date of submission. *

Yes

Legal *

The purpose of this agreement is to outline the terms and conditions of faculty participating in educational activities certified for continuing education credit. The faculty noted above has reviewed, understands, and accepts the responsibilities outlined in the enclosed confirmation letter and the following rules as required by the approved provider in accordance with guidelines set forth by Pinnacle Conference in alignment with Joint Accreditation. DISCLOSURE: All faculty must complete and submit a written disclosure form prior to the presentation and declare that the information provided is complete and truthful to the best of their knowledge. Faculty are required to disclose the existence of any financial relationship they have with the commercial supporter, or other ineligible entities as defined by the ACCME Standards for Integrity and Independence. Pinnacle Conference is responsible for identifying and mitigating any potential conflicts of interest in compliance with the 2020 updated ACCME Standards for Integrity and Independence. FREE OF COMMERCIAL BIAS: Faculty are required to prepare non-biased, fair, and balanced presentations that are objective and scientifically rigorous. Furthermore, presentations should be based on the best available evidence and scientific methods generally accepted in the medical community. Personal anecdotes or recommendations based on your personal experience/clinical practice should only be mentioned when evidence-based data is also cited to support the information being discussed. USE OF GENERIC NAMES: Educational presentations must give a balanced view of therapeutic options. To contribute to this impartiality, faculty are asked to use generic names when referring to therapeutic treatment options. If trade names are used, then those of several companies should also be mentioned rather than only that of a single company. UNLABELED OR OFF-LABEL (non-FDA-approved) USES OF PRODUCTS: Faculty are required to disclose to the audience when unlabeled use of a commercial product, or an investigational use not yet approved for any purpose, is discussed in their presentation. In addition to disclosure, faculty are also required to reference the best available evidence supporting the discussed usage. COMMERCIAL SUPPORTER INFLUENCE: Faculty are not permitted to receive any direct funds or gifts from the commercial supporter(s) of this activity as it relates to this specific activity, nor should they be subject to direct input from a commercial supporter regarding the content of their presentation. COPYRIGHTED MATERIALS: Faculty are responsible for obtaining permissions for all copyrighted materials used in their presentations. Faculty retain copyright in all original materials they contribute to the development of an educational activity. IMAGE AUTHENTICITY: Faculty are responsible to ensure that all visual images provided to Pinnacle Conference, LLC for use in this specific activity do not misrepresent or falsify the treatment outcomes described. Any modifications made to better represent the education must be explained and disclosed to the learner. Do you agree to allow Pinnacle Conference, LLC to use your name, picture and recorded educational content in our podcast promotion, program announcements including but not limited to email, (including using your name as the from field and/or in the subject line), outcomes survey email, social media outlets (Facebook, Twitter, LinkedIn)?

Yes

No

Today's Date *

Please enter the date of completion of this form.

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