SR KSA Disclosure
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DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM
 
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
 
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If you marked "A" sign below.

If you marked "B" I will send you our full disclosure form.

I have read the Minnesota Academy of Family Physicians Policy and Procedures for Managing Conflicts of Interest. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether this relationship precludes my participation, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will disqualify me from participating in this activity.

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