AG19830307 - Laserfiche WebLink

Home Browse Search

B.' CONSUMER/PROVIDER DETERMINANTS 1. [Please respond to the following questions by writing yes or no in the spaces provided.] (A) Are you a direct provider of health care (including a physician, dentist, nurse, podiatrist, optometrist, physician assistant, or ancillary personnel employed under the supervision of a physician) in that your primary current activity is the provision of health care to individuals or the administratioo of facill- ties or institutions (including hospitals, long-term care facilities, rehabilitation facilities, alcohol and drug abuse treatment facilities, outpatient facilities, and health maintenance organizations) in which such care is provided and, when required by State law, you received professional training in the provision of such care or in such administration and are licensed or certified for such provision or administration; if yes, please specify: (B) Do you receive (either directly or through your spouse) more than one-fifth of your gross annual income from any one or combination of (1) fees or other compensation for research into or instruction in the provision of health care; (2) entities engaged in the provision of health care or in research or instruction in the provision of health care; (3) producing or supplying drugs or other articles for individuals or entities for use in the pro- Vision of or in research into or instruction in the provision of health care; or (4) entities emgaged in producing drugs or such other articles; (C) Do you hold a fiduciary position with, or have a fiduciary interest in, any entity described in (2) Or (4) of B above; if yes, please specify: (D) Are you a member of the immediate family (spouse and/or children living in the same household) of an individual described in (A), (B), or (C) above; (E) Are you engaged in issuing amy policy or contract of individual or group health insurance or hospital or medical service benefits. 2. Public Official: Elected Appointed Please specify position 3.Private or Public Agency Representative Identify agency Name and affiliation of person making nomination, if other than nominee: Name Cplease print] Signature I agree to serve as a member of the SP||SA Governing Body if elected ~o such position at the next Annual Meeting or in the interim to complete an unex- pired term. Date Signature of Nominee FOR USE BY GENERAL PURPOSE LOCAL GOVERNMENTAL UNITS [e.g., County, City, Town Governments] Should the above nominee be elected to a seat on the SPHSA Governing Body, the nominee (will ) (will not ) be accepted as a representative of our government jurisdiction. Signature of Person Authorized to Act for Jurisdiction ECompleted Nomination Forms must be received in the SPHSA office by April 18, 1983.]