Medical Staff Conflict of Interest Disclosure Form

Managing conflicts of interest in healthcare settings is essential for maintaining trust, ensuring ethical patient care, and complying with regulatory requirements. This Medical Staff Conflict of Interest Disclosure Form provides healthcare organizations—including hospitals, clinics, medical practices, and research institutions—with a structured way to collect and review potential conflicts from physicians, nurses, researchers, and other clinical staff.

The form captures outside employment, consulting arrangements, board positions, equity interests, sponsored research, speaking fees, and other financial relationships that may influence clinical decision-making, research outcomes, or institutional policy. By collecting this information annually or upon onboarding, healthcare administrators and compliance officers can identify, evaluate, and manage potential conflicts proactively.

Built with Paperform, this template includes conditional logic to reveal additional detail fields only when staff report specific types of relationships, keeping the form streamlined for those with nothing to disclose while capturing comprehensive information when needed. Submissions can be routed automatically to compliance teams, and eSignatures can be collected via Papersign to formalize acknowledgment and attestation.

For organizations managing disclosure workflows across multiple departments or reviewing conflicts in committee, Stepper can automate the review process—routing flagged disclosures to department heads or conflict review boards, triggering follow-up requests for clarification, and logging decisions in your compliance management system.

Whether you're a hospital system ensuring regulatory compliance, a research institution managing NIH or industry-funded studies, or a private practice formalizing ethical standards, this template helps you maintain transparency, protect patient care, and meet accreditation requirements with a clear, professional disclosure process.