TX HHS Form 8607. Conflict of Interest Screening of a Representative of the Office

The TX HHS Form 8607, "Conflict of Interest Screening of a Representative of the Office", is a crucial tool for ensuring the integrity and credibility of the Long-Term Care Ombudsman Program. This form helps identify potential conflicts of interest that may impact an individual's ability to effectively represent the program.

The form requires representatives to disclose their personal and professional relationships with Long-Term Care facilities, Day Activity and Health Services (DAHS), Home and Community Support Services Agencies (HCSSA), and other organizations. Specifically, it asks about ownership or investment interests in these entities, as well as any employment history that may create a conflict of interest.

This form should be used by certified ombudsmen and their interns to screen themselves for potential conflicts before performing program functions and annually thereafter. The form's instructions emphasize the importance of immediate notification to the managing local ombudsman (MLO) if a conflict of interest is identified or suspected. By completing this form, representatives can ensure that their personal interests do not compromise the Ombudsman Program's mission.