A sample vendor disclosure statement and certification form (Disclosure Statement) for use by hospitals, surgery centers, health systems, physician group practices, and other similar health care organizations, facilities, and entities to screen and vet vendors of medical products and supplies for conflicts of interest, including direct and indirect financial relationships with competitors and referral sources (such as physicians or other health care professionals and organizations). This Standard Document is based on federal law and requirements applicable to federal health care program participants. State and local law may impose different or additional requirements; however, this document can be a useful compliance tool for those jurisdictions with rules modeled on federal health care laws related to health care conflicts of interest and referral relationships.