24th Annual MSF Financial Relationship Disclosure for CME Planners Name(Required) First Last Role(Required)(e.g., Planning Committee Member, CME Committee Chair, Activity Director, Speaker,Moderator, Panelist, etc.)Activity or Conference Title: Montana State Fund 24th Annual Medical Conference Activity Date OR Planning Year for which Disclosure is Valid: May 6 – 8, 2026 The purpose of this form is to identify and resolve all potential conflicts of interest that arise from financial relationships with ineligible companies. The ACCME defines an ineligible company as any entity producing, marketing, selling, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME considers financial relationships a conflict of interest when individuals have both a financial relationship with an ineligible company and the opportunity to affect the content of CME. Please indicate all financial relationships with ineligible companies you have had within the last 24 months relating to the content of the educational activity. Note: The ACCME does not consider providers of clinical services directly to patients to be ineligible companies unless the provider is owned or controlled by a commercial interest. Planners need only complete a disclosure form once each year. However, if your financial relationships change, you must submit a new disclosure form. I understand By checking this box, I affirm that I will notify the UMA Foundation if my financial relationships change and will submit a new disclosure form for activities in which I have control of content.(Required) I agree Check one of the boxes below(Required) I have no financial relationships with any entity producing, marketing, selling, re-selling, or distributing healthcare goods or services consumed by, or used on, patients. I disclosed all financial relationship(s) with entities entity producing, marketing, selling, re-selling, or distributing health care goods or services consumed by, or used on, patients: Please indicate any financial relationships with ineligible companies you have had within the last 24 months.(Required)CompanyType of Relationship*Product/ Clinical Area Add Remove*Type of relationship may include independent contractor, consultant, advisory committee, board membership, expert panel, research or other grant recipient, paid speaker or teacher, membership on advisory committees or review panels, intellectual property/patent holder, ownership interest (product royalty/licensing fees, owning stocks, shares, etc) or any other financial relationship.Date MM slash DD slash YYYY Electronic Signature(Required) First Last
