Maryland Health Services Cost Review Commission Trustee Disclosure of Interest Statement
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1.
Enter your email address to receive a copy of this form:
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2.
DATE OF STATEMENT:
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3.
PERIOD COVERED:
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FROM:
TO:
MM/DD/YYYY
MM/DD/YYYY
4.
TRUSTEE, DIRECTOR, OR OFFICER NAME:
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5.
TRUSTEE, DIRECTOR, OR OFFICER BUSINESS ADDRESS:
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6.
HOSPITAL NAME:
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--Please Select--
Adventist HealthCare Fort Washington Medical Center
Adventist Healthcare Germantown Emergency Center
Adventist Healthcare Rehabilitation
Adventist HealthCare Shady Grove Medical Center
Adventist HealthCare White Oak Medical Center
Anne Arundel Medical Center
St. Agnes Hospital
Atlantic General Hospital
Brook Lane Psychiatric Center
CalvertHealth Medical Center
ChristianaCare, Union Hospital
Doctors Community Hospital
Edward McCready Memorial Hospital
Encompass Rehabilitation of Southern Maryland
Frederick Health
Garrett Regional Medical Center
Grace Medical Center
Greater Baltimore Medical Center
Holy Cross Hospital
Holy Cross Germantown Hospital
Howard County General Hospital
Johns Hopkins Bayview Medical Center
Johns Hopkins Health System
Johns Hopkins Hospital
Kennedy Krieger Institute
McCready Health Pavilion
Medstar Franklin Square Hospital
Medstar Good Samaritan Hospital
Medstar Harbor Hospital
Medstar Health System
Medstar Montgomery General Hospital
Medstar Southern Maryland
Medstar St. Mary's Hospital
Medstar Union Memorial
Mercy Medical Center
Meritus Medical Center
Mt. Washington Pediatric Hospital
Lifebridge Carroll Hospital
Lifebridge Health System
Lifebridge Levindale Geriatric Center & Hospital
Lifebridge Northwest Hospital
Lifebridge Sinai Hospital of Baltimore
Peninsula Regional Medical Center
Sheppard Pratt Health System
Suburban Hospital
University of Maryland Health System (UMMS)
University of Maryland Hospital (UMMC)
University of Maryland - Baltimore Washington Medical Center
University of Maryland - Capital Regional Health
University of Maryland - Charles Regional Medical Center
University of Maryland - Harford Memorial Hospital
University of Maryland - Midtown Campus
University of Maryland - Rehabilitation & Orthopedic Institute
University of Maryland - St. Joseph Medical Center
University of Maryland - Shore Regional Health
University of Maryland - Upper Chesapeake Medical Center
Western Maryland Health System
7.
HOSPITAL ADDRESS:
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8.
TRUSTEE, DIRECTOR, OR OFFICER'S BUSINESS ENTITY NAME:
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9.
TRUSTEE, DIRECTOR, OR OFFICER’S BUSINESS ENTITY ADDRESS:
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10.
MAJOR BUSINESS, PROFESSIONAL, OR ACADEMIC ACTIVITY OF TRUSTEE, DIRECTOR, OR OFFICER'S BUSINESS ENTITY:
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11.
TITLE, RELATIONSHIP, OR POSITION OF TRUSTEE, DIRECTOR, OR OFFICER IN THE BUSINESS ENTITY:
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12.
TYPE OR NATURE OF BUSINESS TRANSACTIONS, DEALINGS, OR SERVICES BY AND BETWEEN THE HOSPITAL TRUSTEE, DIRECTOR, OR OFFICER'S BUSINESS ENTITY HAVING AN ACTUAL OR IMPUTED VALUE OR WORTH OF $10,000 OR MORE TO THE TRUSTEE, DIRECTOR, OR OFFICER’S BUSINESS ENTITY:
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13.
MONETARY VALUE OF THE BUSINESS TRANSACTION(S)TO THE TRUSTEE, DIRECTOR, OR OFFICER'S BUSINESS ENTITY:
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DECLARATION OF TRUSTEE, DIRECTOR, OR OFFICER THAT THE STATEMENT IS TRUE TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION, AND BELIEF THAT THIS STATEMENT IS TRUE AND CORRECT UNDER PENALTIES OF PERJURY:
14.
SIGNATURE OF TRUSTEE, DIRECTOR, OR OFFICER:
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15.
PRINTED NAME OF TRUSTEE, DIRECTOR, OR OFFICER:
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