Provider Annual Education

Required Annual Provider Education – Please review all of the documents below.

For Tomah Health Providers with admitting privileges:

Required Annual Provider Education Form

"*" indicates required fields

Conflict of Interest Policy*

I have read the Conflict of Interest Policy above. I agree to comply with all of the terms and conditions therein.

Please check an option and disclose relationships if applicable:

I have no organizational relationships or other circumstances to disclose under Tomah Health's Conflict of Interest Policy as reviewed above.

I hereby disclose the following organizational relationships or circumstances for review by Tomah Health's Chief Executive Office and Board of Directors to determine whether I have any actual or potential Conflicts of Interest. Please enter your relationship/circumstances in the comment box below.

Conflict of Interest relationship or circumstances

Annual Education Submission

Signature*

I understand that typing my First and Last name in the fields below constitutes as my electronic signature.

Name*

First Last

Health System Affiliation & Specialty*

Email*

Updated: 1/22/25 MH