AG19811020 - 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 administration of facili- ties or institutions (including hospitals, long-term care facilities, rehabilitation facilities, alcohol and drug abuse treatment facilities, outpatient facilities, and health m~aintenance 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 administrat~on~ if yes~ please specify: (B) Do you receive (either directly or through yaur 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 ~rovision of health care; (2) entities engaged in the provision of healtb 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 engaged in producing drugs or such other articles; (C) Do you hold a fiduciary position with, o~ have a fiduciary interest in, any entity.described in (2) or (4) of B above; if yes, please specify: (D) Are you a ~ember of the immediate family (spouse and/or children living in the~same:household) of an i~dividual described in (A), (B), or (C) above: (E) Are you eo~aged in issuing any policy or contract off, 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 [p~ease print] .'Signature I agree to serve as a member of the SPNSA G6v6rning B6dy if elected to such position at the next Annual.Me~ting or in the interim to complete an unex- pired term. FOR USE BY GENERAL PURPOSE LOCAL GOVERNMENTAL UNITS .[e.g., County, City, Town Governments] Should the above nemi~ee be elected to a seat on the SPHSA Governing Body, the nominee Iwill ) (will not ) be accepted as a representative of our goverm~ent~diction. -- Signature of Person Authorized to Ac~ for Jurisdiction [Completed Nomination Forms must b~ received in the SPHSA Office by November 16, 1981.]