CONFLICT OF INTEREST DISCLOSURE STATEMENT
Relationship to Sterling Healthcare: ( one or more as applicable)
_______Member of Board of Directors
_______Contracted Healthcare Physician
_______Other Contracted Healthcare Provider
CONFLICT OF INTEREST POLICY
Sterling Healthcare has adopted this Disclosure Statement in accordance with its Conflict of
Interest Policy, to assist in the identification of potential conflicts of interest. This Statement is
required of all Board Members, Officers, Senior Management, and other Sterling personnel or
associates who may be in a position to influence Sterling business decisions. The statement will
be signed at the time of appointment, hire, or retention, and annually thereafter. The filing does
not absolve these individuals of their ongoing duty to disclose conflicts of interest which might
influence their judgment or performance in their role with Sterling Healthcare.
This Disclosure Statement does not require you to provide detailed information about your
financial affairs. You are only asked to disclose information pertinent to potential conflicts of
interest. However, if a potential conflict of interest is based on your ownership interest in an
entity that does business with Sterling Healthcare, you are asked to state your percentage of
ownership in such business. If you are uncertain as to whether or not you should disclose a
particular relationship, you can request guidance from the Compliance Officer of the General
Counsel of Sterling Healthcare.
1. Are you an officer, director, or employee of, or do you have an ownership or other direct or
indirect financial interest in any business which contracts with or otherwise does business
with Sterling Healthcare? If your answer is “yes”, please explain and if your interest is one
of ownership, please state your percentage of ownership.
2. Is a member of your family an officer, director or employee of, or does such family member
have an ownership or other direct or indirect financial interest in any business which
contracts with or otherwise does business with Sterling Healthcare? If your answer is “yes”,
3. Are you or is a member of your family an officer, director or employee of, or do you or such
family member have an ownership or other direct or indirect financial interest in any business
which might be benefited by or affected adversely by a decision of the Board of Directors or
the management of Sterling Healthcare? If your answer is “yes”, please explain.
4. Do you have any relationship with any person or entity which might influence your judgment
if a matter involving that person or entity came before the Board of Directors or the
management of Sterling Healthcare? If your answer is “yes”, please explain.
5. Have you reported to the Sterling Healthcare Compliance Officer, all gifts or gratuities
valued at more than $100, that you received over the past year as part of your employment
or association with Sterling Healthcare? If your answer is “no”, please list and explain.
After providing your responses to the above questions, please sign this document below. By
your signature you are stating that:
1. You have received a copy of the Policy.
2. You have read and understand the Policy.
3. You agree to comply with the Policy.
4. You understand that the policy applies to all activities involving Board delegated powers, or
management decisions of Sterling Healthcare.
5. You understand that you have an obligation to maintain the confidentiality of all information
and materials shared with you in connection with your work as a Board member or a member
of management of Sterling.
Position Held (please print)