Policy Manual sample

MDT Home Health Care Agency, Inc. INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST (Board of Directors) I have read and am fully familiar with the Agency's policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly as a result of my membership on the Agency's Board of Directors or its committees or my employment. Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the Agency's business that might result in any profit or gain, directly or indirectly, for myself. Explain any possible conflict of interest (Example working for another Agency, Hospital, etc): ______________________________________________________________________________ ______________________________________________________________________________ _______________________________ Signature _______________________________ Date Home Health Agency Policies A-95