AOA/PIM Disclosure Form 62nd Annual Spring Meeting - 2022April 28-30, 2022Virtual - On Demand • Carlsbad, CA DISCLOSURE FORM FOR: Matthew Koepplinger, DO, FAOAOIf you are not Matthew Koepplinger, DO, FAOAO, you must close your web browser completely and re-login. | Return to Faculty Forms . Contact Information Name: Matthew Koepplinger, DO, FAOAO Academic Title:* Academic Institution:* Preferred Mailing Address:* 2711 Waters Lake Lane Missouri City, TX 77459 Phone Number: Fax Number: E-mail Address:* It is the policy of the AOAO to ensure balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. All faculty participating in any AOAO sponsored programs are expected to disclose to the activity audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education activity. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It remains for the audience to determine whether the speaker's outside interests may reflect a possible bias in either the exposition or the conclusions presented. Please disclose all financial relationships you have had in the past 24 months with ineligible entities (definition below). For each financial relationship, enter the name of the entity and the nature of the financial relationship. There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible entities. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education. You do not need to disclose financial relationships of your spouse or partner. Financial Relationships for Planners, Faculty, and Others in Control of Activity Content Faculty, planners, and managers who affect the content of a CME/CE activity are required to disclose their own financial relationships, as well as relationships to products or devices their spouse/life partner have, with commercial interests related to the content of this CME/CE activity of any amount over the past 12 months. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected (honoraria received from a CME/CE provider for serving as a CME/CE faculty member by you or your spouse/life partner, even though those funds may have been provided through an educational grant from a commercial interest, DO NOT HAVE TO BE DISCLOSED). A commercial interest is defined by the ACCME, AAPA, ACPE, ANCC, and ARBO/COPE as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients. Relationships with governmental agencies (e.g., the NIH) do not have to be disclosed. 17048-LJ - Activity: 2022 AOAO Annual Fall Meeting Your Name: I am a/an: Faculty Member Planner/Manager Other An ineligible entity is any entity whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. For specific examples, visit accme.org/standards. Nature of Relationship Company/Companies Employee/Owner Yes No Grant/Research Support Yes No Speakers Bureau/Honoraria for non-CME Yes No Consultant/Advisory Board Yes No Non-Mutual funds Stock Ownership/Stock options Yes No Patent Holder/Royalties paid to you Yes No Other financial or material support Yes No In the past 24 months, I have not had any financial relationships with ineligible companies. I attest that the above information is correct as of date of submission. Signature: Date: The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.
