TX HHS Form 2115. Conflict of Interest Notification

The TX HHS Form 2115, Conflict of Interest Notification, is a crucial document that helps resolve potential conflicts of interest in various situations. Typically filled out by providers, provider employees, or applicants, this form ensures transparency and accountability within the Texas Health and Human Services (HHS) system.

This form is designed to notify first-line supervisors of potential conflicts of interest, which may arise from individual or applicant relationships. Key features include a clear description of the nature of the potential conflict, as well as a declaration that there is no conflict of interest. In cases where a conflict does exist, staff must take specific steps to address the issue.

When completing this form, users are required to provide essential information about the provider or applicant, including their name and SSN. The form also outlines responsibilities for supervisors, including reviewing and approving the notification. By using this form, HHS ensures compliance with relevant government codes and regulations, such as Government Code Sections 552.021, 552.023, and 559.004.

• This form is typically used to notify first-line supervisors of potential conflicts of interest.
• It is designed for providers, provider employees, or applicants within the Texas Health and Human Services (HHS) system.
• The form requires users to provide essential information about the provider or applicant, including their name and SSN.