Healtheast Employee Research Financial Disclosure Form

HEALTHEAST EMPLOYEE RESEARCH FINANCIAL DISCLOSURE FORM

The undersigned HealthEast employee does hereby certify that employee, except as disclosed below, has not (and will not), in connection with or related to any research or work (the "Project") being performed by any person at any HealthEast facility, solicited, accepted or received, whether directly or indirectly, any money, money equivalents, stock, bonds, options, products, services, gifts, favors, reimbursements or any other Remuneration or gratuity ("Remuneration"), other than from HealthEast, including but not limited to the following:

a)Fees for services, grants, consulting fees, honoraria, speaking fees, gifts, favors, or a management or board position from any entity which may financially benefit from the Project;

b)Reimbursement or credit from any entity which may financially benefit from the Project;

c)Buying, selling or receiving stock, securities, options or other investment vehicles from any entity which may financially benefit from the Project;

d)Circumstances under which employee stands to benefit financially or otherwise for referring patients to or enrolling patients in, or encouraging patients to enroll in, the Project;

e)Participation by employee in educational activities supported by any entity which may financially benefit from the Project;

f)Participation by employee in other research activities supported by any entity which may financially benefit from the Project;

g)All financial ties, directly or indirectly, of any kind between employee and any entity which may financially benefit from the Project; and

h)All financial ties, directly or indirectly, of any kind between any HealthEast employee including but not limited to physicians, physician's assistants, nurses, secretaries, office staff and other professional associates, and any entity which may financially benefit from the Project.

Employee further certifies that to the best of his or her knowledge except as disclosed below the spouse, domestic partner (as that term is generally understood), parents, children and spouses of children, brothers and sisters and spouses of brothers and sisters of employee has not (and will not) solicited, accepted or received, any Remuneration. For purposes of this statement, a person is deemed to have solicited, accepted or received any direct or indirect Remuneration if an organization in which such person or the spouse, domestic partner (as that term is generally understood), parents, children and spouses of children, brothers and sisters and spouses of brothers and sisters of the person or any combination of them has a financial interest, has solicited, accepted or received any direct or indirect Remuneration other than from HealthEast.

The term HealthEast includes all affiliates, subsidiaries, and clinics owned or operated by HealthEast.

For each disclosure, provide source, amount, and a description of the Remuneration or gratuity received:

(Use additional pages if space is required).

Employee SignatureDate

(Please print name below)

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Last Modified: 07/03/1997