Annual Conflict of Interest/Financial Disclosure

Relationship to DRH Health (DRH). Indicate your relationship to Duncan Regional Hospital, Inc. ("DRH"):

I acknowledge and agree to abide by the Conflicts of Interest Policy of DRH ("Policy") which requires me to:
a. Disclose the existence and nature of any Financial Interest that may give rise to an actual, perceived or potential Conflict of Interest in accordance with the Policy.
b. Put the interest of DRH and its Affiliates before a personal interest in any business or corporate opportunity which I learn of in my role for DRH or its Affiliates.
c. Abstain from participating and absent myself from any meetings, decisions or matters where I have an actual, perceived or potential Conflict of Interest.
d. Not accept any favor, payment in cash or in kind, gifts (other than those given in recognition for service or achievement from DRH or its Affiliates), or other items of service of value from any third party in exchange for influencing the actions of DRH or its Affiliates.
e. Supplement this disclosure in the event that a Conflict of Interest, that has not yet been disclosed, arises.

Compensation Committee
If I serve on a Compensation Committee of DRH Health or its Affiliates, I agree not to vote on matters that will affect my personal compensation or the compensation of those similarly situated. I understand that I may provide general information on compensation.

Disclosure of Interests

Financial Interests
List and describe any Financial Interest that you or an immediate family member have, including ownership and investment interest, in vendors or consultants to DRH or its Affiliates, or in a business that competes with DRH or its Affiliates. Include direct ownership of securities of a publicly traded company with greater than five percent (5%) ownership. Financial interests include arrangements such as ownership in a surgery center, consulting or other compensated arrangements with a drug company, medical equipment supplier or similar companies. Check "None" above if you have no Financial Interest to disclose.
List any contracts or other written or verbal agreements you may have with DRH or its Affiliates. Check "None" if you have no contracts to disclose.
Gifts and Favors
List any gifts or favors received in your capacity as a DRH leader, board member or medical staff member. Examples include non-business meals, travel, tickets to sporting or other non-charitable events or discounts. If you are a non-employed physician, include gifts given to you or an Immediate Family Member by DRH or its Affiliates. Check "None" if you have no gifts or favors to disclose.
Other Potential Conflicts
List and describe any other situations including board membership, employment, business or professional activity that may conflict with your duties and responsibilities for DRH or its Affiliates. Check "None" if you have no potential conflicts to disclose.
Relationship to Principal Officers or other Employees of DRH or its Affiliates
If you have an immediate family member relationship with a Principal Officer or other employee of DRH or an Affiliate, provide the name of the individual and your relationship to that individual. Check 'None" if you have no family relationship to a Principal Officer or other employee of DRH or its Affiliates.

I affirm that the responses provided in this Annual Conflict of Interest/Financial Interest Disclosure Form are true and accurate to the best of my knowledge, and that this disclosure was personally completed by me.

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