Business Code of Conduct | AltaMed Foundation

Page i of 21

Business Code of Conduct

AltaMed Health Services Corporation

2040 Camfield Avenue, Los Angeles, CA 90040

Revised February 2020. Reviewed and approved by the Board of Directors on 02/27/2020

Page ii of 21

TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................................................................ii

A Message From Our President & CEO..................................................................................................................1

The Business Code of Conduct ..............................................................................................................................2

About Our Code.........................................................................................................................................................2

Who Does It Apply To? ..............................................................................................................................................2

Questions About Our Code ........................................................................................................................................2

Our Shared Responsibilities..................................................................................................................................3

Reporting Concerns ...................................................................................................................................................3

Response to Violations ..............................................................................................................................................3

Anti-Retaliation Policy...............................................................................................................................................4

Supportive Working Environment.........................................................................................................................5

Non-Discrimination ...................................................................................................................................................5

Physical Safety...........................................................................................................................................................5

Alcohol and Drug Free Workplace.............................................................................................................................5

Wage and Hour Practices..........................................................................................................................................5

Financial Integrity.................................................................................................................................................6

Accurate and Complete Financial Records ................................................................................................................6

Records Management ...............................................................................................................................................6

Refund of Overpayments...........................................................................................................................................6

Co-payments and Discounts......................................................................................................................................6

Doing The Right Thing...........................................................................................................................................7

Making Ethical Decisions...........................................................................................................................................7

Medical Ethical Consultation.....................................................................................................................................7

Cooperation With Government Audits And Investigations .......................................................................................7

Honest Dealing With Government Officials ..............................................................................................................7

Fraud, Waste and Abuse ...........................................................................................................................................8

Inappropriate Referrals .............................................................................................................................................8

The False Claims Acts ................................................................................................................................................8

Penalties....................................................................................................................................................................8

Additional Information..............................................................................................................................................9

Conflicts of Interest ............................................................................................................................................10

Page iii of 21

Conflict Of Interest – Personal Financial Interests...................................................................................................10

Disclosure, Determination and Management of Conflicts of Interest .....................................................................11

Failure to Disclose ...................................................................................................................................................11

Disclosure to Federal Funding Agencies ..................................................................................................................12

Family and Personal Relationship Employment ......................................................................................................12

Employment Obligations.........................................................................................................................................12

Honoraria ................................................................................................................................................................12

Gifts/Gratuities .......................................................................................................................................................12

Free Business Competition ......................................................................................................................................13

SAFEGUARDING INFORMATION AND RESOURCES...............................................................................................14

Protected Health Information (PHI) ........................................................................................................................14

Confidential Business Information ..........................................................................................................................14

Intellectual Property................................................................................................................................................15

Use of Company Assets and Resources ...................................................................................................................15

Using Technology Responsibly ................................................................................................................................15

HEALTHCARE ADVOCACY....................................................................................................................................15

Advocacy Activities..................................................................................................................................................16

Political Activities ....................................................................................................................................................16

Bribery.....................................................................................................................................................................17

Conclusion..........................................................................................................................................................18

Page 1 of 21

A MESSAGE FROM OUR PRESIDENT & CEO

At AltaMed, we work boldly and live brilliantly.

Our brand is as much a reflection of the courageous individuals who see what needs to be done and

boldly find ways to make it happen. We apply this positive energy to their work, family, community and

even their own personal growth. This means that each of us is personally responsible for creating a work

experience that promotes ethical conduct, accountability, and trust – for ourselves, our colleagues, our

consumers, our regulators, and the communities who depend upon us.

As we work together both to provide the highest quality care without exception, we must likewise

exercise the highest standards of ethics and professional behavior, as outlined on our Business Code of

Conduct. The Code serves as a guidebook to acting morally and with integrity as representatives of

AltaMed in our decisions, operations, and the execution of our work and responsibilities.

With this in mind, I request that you read and understand AltaMed’s Business Code of Conduct. Even if

you’ve read it before, please review it again. By carefully reviewing and understanding the standards

and guidelines of the Code, you are building upon AltaMed’s long-standing commitment to delivering

the highest level of excellence in all that we do. Modeling our values in all areas of our business is core

to who we are as a company and strengthens our consumers’ confidence in knowing that we will always

conduct ourselves ethically as we improve health outcomes and reduce healthcare disparities.

If you identify something you believe is not in accordance with our values or our Standards of Ethical

Business Conduct, please speak up. You have several ways to seek guidance or to anonymously report

concerns, which are specifically outlined in our Code. We are grateful to associates who take the

initiative to report unethical behavior, and associates should know that retaliation of any kind is

unacceptable.

As a leader in healthcare, AltaMed can only achieve our mission, vision, and core values if we remain

committed to ethical conduct. Thank you for your continued commitment to doing the right thing –

without compromise – for those whom we are privileged to serve.

Castulo de la Rocha

President & CEO

Page 2 of 21

THE BUSINESS CODE OF CONDUCT

About Our Code

AltaMed Health Services Corporation’s (“AltaMed’) mission is to eliminate disparities in health care

access and outcomes by providing superior quality health and human services through an integrated

world-class delivery system for Latino, multi-ethnic and underserved communities in Southern

California.

The Business Code of Conduct (“the Code”) is a vital part of how we achieve our mission and vision and

maintain our core values. It sets forth the operational procedures for ethical conduct (including, but not

limited to, disclosure and management / mitigation of conflicts of interest, reporting of concerns,

disciplinary actions for non-compliance with the Code) which all employees, agents and board members

must comply. It will periodically be updated to support changes in the company, laws & regulations,

and/or other requirements.

Who Does It Apply To?

The Code applies to AltaMed’s employees, physicians, health care professionals, trainees, agents, board

members, volunteers, representatives, contractors, vendors and other persons or companies working

with AltaMed to provide products or services to or on behalf of AltaMed.

The Code requires each of us to follow all applicable laws, regulations, and internal policies related the

work we do for AltaMed. This includes maintaining a healthy, learning, professional environment

staffed by individuals who are committed to integrity and ethical conduct. The Code also:

 Affirms AltaMed’s commitment to integrity and ethical behavior, as a leading community-based

provider of quality health care and human services.

 Provides standards of conduct that binds all employees, agents and board members to certain

ethical requirements.

 Includes disciplinary actions for noncompliance, as needed.

Questions About Our Code

There may be situations where requirements differ from the standards outlined in this Code. If you

come across such a case, or have questions about laws, regulations, policies, or the Business Code of

Conduct, please discuss the matter with your supervisor or reach out to the Office of Compliance & Risk

Management at AltaMed’s Corporate Headquarters.

Page 3 of 21

OUR SHARED RESPONSIBILITIES

Taking personal responsibility and accountability for our actions is critical to the success of our company.

We each own accountability at a professional and personal level at all times. This means:

 Doing what we say we will do

 Demonstrating accountability and performance-based behavior

 Supporting each other’s work

 Being transparent, honest, and direct

 Knowing the rules that apply to your work and seeking advice when needed

 Proactively seeking to resolve problems and addressing issues when they come up

Reporting Concerns

AltaMed expects everyone to do their part to protect our reputation, our

company, and our customers. If you come across a something that you

suspect to be a violation of this Code, of AltaMed policies, or other laws and

requirements, you have a duty to report it right away. Failure to report the

concern may result in disciplinary actions, which may include termination of

employment or affiliation.

Do not investigate and confirm issues before reporting them. Whenever

possible, use of the chain-of-command to address a potential violation.

However, if, for any reason, you are uncomfortable letting your supervisors

know about your concern, report it directly to the Office of Compliance and

Risk Management (“OCRM”) confidentially or anonymously using any of

following methods:

 Call the 24 Hour Toll Free Compliance Hotline at 888-418-1398

 File an online report at MyComplianceReport.com (ID is ALTA)

 Write to the Chief Compliance Officer at AltaMed’s Corporate

Headquarters

The OCRM is committed to a prompt and fair review and response to any reported matter.

Response to Violations

When an internal review substantiates a reported violation, AltaMed is committed to:

 As immediately as possible, stop the non-compliant conduct or practice

 Initiating corrective action, which may include, but is not limited to, process improvement,

disciplinary actions (such as oral admonishment, written reprimand, re-assignment, demotion),

suspension or termination of employment or affiliation (which for board members, may include

removal from the Board of Directors), and/or requiring contractors to arrange for prompt

restitution, as appropriate

 Notifying the appropriate governmental agencies and/or health plans

 Implementing systemic changes to prevent a similar violation from recurring

Please know that certain violations may carry extra consequences, like exclusion from participation in

Medicare and Medicaid programs, fines, criminal prosecution, and jail time.

Q - If I anonymously report

a concern through the

hotline, how do I know it is

being addressed by the

OCRM?

A - Every person using the

Hotline is given a code for

online checks and updates,

letting you know how the

matter is being handled.

Please keep in mind that

certain details will continue

to remain confidential, but

you will receive general

updates and information

about you concern.

Page 4 of 21

Anti-Retaliation Policy

Having the courage to say and do what is right can sometimes be difficult. Because of this, AltaMed

strictly prohibits any punishment, retaliation, or negative consequences for reporting concerns in good

faith to management and/or the OCRM. If you feel you are being retaliated for reporting, contact the

OCRM for support. Any person who retaliates against another person for the reporting of (or his/her

participation in addressing) potential noncompliance shall be subject to the disciplinary actions

discussed above.

So, take action when you believe our Code, AltaMed policies, or other laws and requirements may have

been or may be violated. Raising problems before they become bigger issues is essential to operating

with integrity and to protecting AltaMed communities.

Page 5 of 21

SUPPORTIVE WORKING ENVIRONMENT

AltaMed is committed to providing a safe, healthful and productive work environment. Each employee

has a personal responsibility to report conditions and circumstances that undermine this environment.

Non-Discrimination

We provide equal opportunity in employment and care and services to our communities. No one shall

experience discrimination at AltaMed because of race, color, religion, sex, gender (including gender

identity), age, national origin, marital status, sexual orientation, veteran status, disability, genetic

information, and/or any other statuses or conditions protected by applicable federal, state or local laws,

except where a bona fide occupational qualification applies.

Physical Safety

AltaMed is committed to and serious about providing and maintaining a safe and healthy work

environment. It is everyone’s responsibility to report safety concerns, such as:

 Injuries or other illnesses

 Hazards, such as unsafe facility and equipment conditions or malfunctions

 Security violation, criminal conduct, and/or suspicious persons or activity

 Actual or threatened acts of violence or intimidation

Know and follow Safety and Security policies and requirements when

working at AltaMed and when using AltaMed facilities, equipment, and

resources. Be sure you know how to recognize and report potential

workplace risks and safety concerns by checking with your supervisor or

the Safety Officer.

If you need training and/or a refresher to know how to do your job

safely, let your manager know. Respectfully offer feedback to coworkers

if they are not working safely, while accepting feedback when offered. Be

a constructive example for others to follow.

Alcohol and Drug Free Workplace

Working under the influence of drugs or alcohol can create a safety hazard for you and others and can

affect your judgment. That’s why AltaMed expects and requires you to be free from the influence of

these substances while working. All workers are prohibited from possessing, selling, manufacturing or

distributing illegal drugs on AltaMed property and/or when working on behalf of AltaMed. The only

exception is if senior management has specifically approved the possession and serving of alcoholic

beverages for special events.

Wage and Hour Practices

AltaMed pays competitive wages and rates, as benchmarked with other leading companies. As such,

AltaMed complies with all applicable wage and hour laws, rules, and regulations, including minimum

wage, overtime, adherence to meal and rest breaks, and maximum hours. It is expected that all workers

accurately record all hours worked. Report any discrepancies or concerns right away to your supervisor

or contract manager. Timecard records should not be revised without an worker’s written approval.

Did you know ….

There should be at least one Safety

Coordinator at every site. The

Coordinator is a representative of the

Corporate Safety Officer and provides

information about safety policies,

coordinates emergency drills, and

promotes safety initiatives. Be sure

you know who your Site Safety

Coordinator!

Page 6 of 21

FINANCIAL INTEGRITY

Accurate and Complete Financial Records

We are all responsible for protecting the integrity of AltaMed’s records. Our company may face serious

penalties or consequences if we don’t keep accurate records of financial transactions and company

information. Accurate and complete records are vital to our decision-making processes and are required

in our collection and reporting of financial, legal and regulatory data. This includes, but is not limited to:

 Reflecting actual services provided when submitting claims for reimbursement to payers, including

Medicaid and Medicare.

 Accurately recording the dates of service, services provided, and diagnoses in health records to

support accurate claim submissions.

 Billing for, only, reasonable and necessary supplies or services as supported by accurate and

complete documentation.

 Compensation is supported by executed contracts, accurate timecards, and other documents to

verify rendered services.

It is strictly prohibited to use inaccurate, disguised, and/or misleading financial, operational, or medical

information used to support regulatory reporting and/or to support eligibility for benefits.

Watch for and report signs of potential fraud, bribery, or money laundering activity. Contact the Office

of Compliance & Risk Management and/or use the Compliance Hotline for questions, concerns, or

suspicious activity.

Records Management

We manage our records properly and retain the records we need to support our tax, financial, and legal

obligations. Always follow our records retention policies and securely dispose of records that are no

longer needed. Remember to never dispose of any information that may be relevant to an investigation

or subject to a litigation hold without first checking with General Counsel at AltaMed’s headquarters.

Refund of Overpayments

AltaMed will adhere to the requirements for returning overpayments to third-party payers and/or

government programs. If AltaMed determines that it has received an overpayment, AltaMed will

promptly refund the payment to the proper party in accordance with appropriate regulations, policies,

and procedures.

Co-payments and Discounts

AltaMed will not waive the collection of insurer co-payment obligations, except as outlined in AltaMed’s

sliding fee scale discount or charity policies.

Page 7 of 21

DOING THE RIGHT THING

Making Ethical Decisions

The Code and our policies cannot replace our own sense of

integrity and good judgment. We are each responsible to do what

is right. Act with unquestionable ethics in all business matters.

Never commit, or ask others to commit, unethical or illegal acts.

Immediately report any request of you to commit an act you

think may be illegal or unethical.

Medical Ethical Consultation

An ethics consultation may help whenever the health care team,

a patient, or the patient’s family have an unresolved ethical

concern. A consultation can offer recommendations that the

members of the health care team, the patient, and/or the

patient’s family may use in their decision-making. A few examples

of this may include:

 Disagreements with End-of-Life Decisions

 Concerns about Decision-Making Capacity

 Ethical obligations to be open about medical errors

Employees can complete and submit an Ethics Consultation

Request Form from AltaMed’s intranet when they come across

these situations. Once submitted, the Ethics Consultation Team

will receive your request directly and begin to review the

presented information.

You have the option to remain anonymous when submitting the Ethics Consultation Request Form.

However, this may make it difficult for the Ethics team to provide you with support and to identify those

patients that need your help.

Cooperation With Government Audits And Investigations

AltaMed will be cooperative and truthful in its dealings with any governmental inquiry or request,

including audits, surveys and certification reviews. If you receive a governmental request for information

or if you are approached by a government investigator, contact your supervisor and the Office of

Compliance and Risk Management immediately so that AltaMed can follow proper procedures in

responding. In fulfilling governmental requests, it is important to be responsive and provide requested

documentation in a timely manner. Respect should be shown for government officials and accurate and

complete information be provided. In no circumstances, should an investigation or government official

be improperly influenced or impeded.

Honest Dealing With Government Officials

AltaMed will deal with government bodies and regulatory agencies in a direct, open and honest manner.

No AltaMed board member, physician, employee, agent or contractor will attempt to improperly

influence actions or decisions made by government bodies, officials, employees or their representatives.

Q - How do I know if doing something

may be unethical or violate the spirit

of our Code?

A - When you face an ethical dilemma,

ask yourself:

 Does it feel right?

 Do you believe it’s consistent with

our Code, our values, and our

policies?

…or the interest of our customers,

coworkers, company, and the

community?

 Would you be willing to be held

accountable for your actions?

 If your actions or involvement were

made public, would you still feel

okay about it?

If you answered “no” to any of these

questions or still feel unsure, stop and

seek ethical consultation from the

Ethical Response Team by submitting

an Ethics Consultation Request Form.

Page 8 of 21

Fraud, Waste and Abuse

AltaMed recognizes the importance of preventing, detecting, and investigating fraud, waste, and abuse

matters, and is committed to protecting and preserving the integrity and availability of health care

resources. Fraud, waste, and abuse is not only harmful to AltaMed and our members, it is also harmful

to our entire industry and healthcare system.

In general, fraud refers to any intentional, deceitful act or omission to obtain or deprive someone –

individuals, companies, or the government – of money or property. Abuse is a broad concept that refers

to an activity that is not consistent with generally accepted business, medical or fiscal standard

practices. Waste involves the unnecessary use and/or overuse services and resources.

Examples may include but are not limited to:

 A provider that knowingly submits claims for medical services

that were not provided and/or falsifying a diagnosis to qualify a

patient for insurance or benefits.

 A company falsifying records to show compliance with certain

contractual or regulatory requirements

 Scheduling and seeing patients for doctor visits that aren’t

medically necessary

 Obtaining payment from the government by error and then

falsifying statements or records to keep the payment

Inappropriate Referrals

The Stark Law, which is directed specifically at physicians, prohibits billing for referrals for certain health

care services to a person or entity with which the referrer or the referrer’s family member have a

financial relationship. The Anti-Kickback Statute, which applies to everyone, prohibits referrals of

patients or other business to any individual or entity in exchange for a benefit. There are few exceptions

to these rules against referrals for private financial gain or other benefits. Contact the Office of

Compliance & Risk Management for additional details and/or guidance.

The False Claims Acts

The state and federal False Claims Acts (FCAs) allows the

government to recover money received through fraud, waste, or

abuse, whether intentional or by deliberate ignorance/reckless

disregard.

The FCAs and AltaMed leadership prohibit retaliation against anyone

who reports fraud, waste, and abuse in good faith. For additional

information about the FCAs and/or what constitutes fraud, waste, or

abuse, please contact the Office of Compliance & Risk Management.

Penalties

If involved in FCA or referral violations, you may be individually liable for up to three times of the loss to

the government, plus civil fines for each occurrence, for violating the FCAs under the civil monetary

penalty law (along with AltaMed and other involved persons or companies). And, penalties for violations

can also include exclusion from participation the Medicare/Medicaid programs (in other words, you will

Q – What is deliberate ignorance?

A - Deliberate ignorance means,

intentionally ignoring a fact when

you have every reason to believe

the existence of it. In other words,

it’s turning a blind eye to something

that you know does not look right

yet not reporting it because you

and/or someone else could get in

trouble or we could lose money.

Q – I think a patient is falsifying

information to qualify for benefits.

What do I do?

A – Report this right away to the

OCRM or the Hotline. We’ll be sure to

quickly review and address the

matter. While not caused by us,

AltaMed has a duty to protect public

benefits and resources.

Page 9 of 21

be ineligible to work with another company that receives directly or indirectly Medicare/Medicaid

payments).

Additional Information

AltaMed maintains a comprehensive Compliance program to combat fraud, waste and abuse. This

program includes new hire and annual refresher training for everyone. Fraud, waste, and/or abuse or

criminal conduct involving our business operations is not allowed and will not be tolerated. For

additional information or guidance, contact the Office of Compliance & Risk Management.

Page 10 of 21

CONFLICTS OF INTEREST

It is the responsibility of each board member, employee, agent and contractor to ensure that he/ she

remains free of conflicts of interest in the performance of his/her job responsibilities with AltaMed. This

includes remaining free of outside activities where personal interests may influence or appear to

influence the ability to make objective decisions.

It is also their responsibility report or disclose any actual or potential conflict of interest to a supervisor

and/or to the Office of Compliance and Risk Management (for employees, agents and contractors), to

the Chairperson of the Board Directors (for board members and the Chief Executive Officer) or to the

Vice-Chairperson (for the Chairperson) for review to determine if the relationship warrants an exception

and/or restriction, as indicated below.

If an actual, perceived or potential conflict of interest exists, AltaMed may take whatever action it

deems appropriate according to the circumstances to address the actual or potential conflict, which may

include but is not limited to, transfer of position(s) or separation of employment. AltaMed reserves the

right to determine if other relationships, engagements or activities not covered specifically under the

Code represent actual or potential conflicts of interest under applicable standards.

Conflict Of Interest – Personal Financial Interests

No board member, physician, employee, agent or contractor may participate in the selection, award or

administration of a contract that uses government funds where he/she or his/her immediate family or

partner has a real or apparent financial (or other type) of conflict of interest involved.

You may not refer customers, members, beneficiaries or those who do business with AltaMed to an

entity in which you or a family member has a financial or other material interest. Some unique situations

may qualify as an exception to this policy.

A person has an “Interest” if he or she has, directly, or indirectly through a family member or business

partner:

 a business relationship (e.g., an actual or forthcoming compensation arrangement whether by

contract or employment) with: (1) AltaMed; (2) an entity with which AltaMed has entered (or is

negotiating to enter) a transaction or arrangement; or (3) an entity that is a competitor or

potential competitor of AltaMed;

 a financial relationship (e.g., a controlling or material ownership, or investment interest,

employment relationship or other relationship that a reasonable person would deem significant)

with or a tangible personal benefit from: (1) an entity with which AltaMed has entered (or is

negotiating to enter) a transaction or arrangement; or (2) an entity that is a competitor or

potential competitor of AltaMed;

 a fiduciary relationship (e.g., Board member or trustee) with: (1) an entity with which AltaMed has

entered (or is negotiating to enter) a transaction or arrangement; (2) an entity that is a competitor

or potential competitor of AltaMed; or

Page 11 of 21

 a personal relationship with an individual who has a business, financial or fiduciary relationship as

defined above. A personal relationship means a relationship based on family, business

partnership, friendship or romance.

Any interest in a company through publicly-traded stocks, bonds or mutual funds available to the

general public shall not constitute an Interest, provided the ownership or investment interest is not

deemed a “significant financial interest,” as defined below.

In general, a “significant financial interest” is ownership by you and/or an immediate family member of

more than one percent of the outstanding securities/capital value of a business entity, or that

represents more than five percent of your total assets and/or those of an immediate family member.

A “Conflict of Interest” arises whenever the Interest of a person competes with or has the potential to

compete with the best interests of AltaMed. A Conflict of Interest is presumed to exist if a person with

an Interest is involved in any way in the transaction or arrangement in which he or she has such Interest.

Disclosure, Determination and Management of Conflicts of Interest

AltaMed requires that all board members, employees, agents and contractors disclose in writing (and

update at least annually): (1) all Interests that may create an actual or potential Conflict of Interest, and

(2) where applicable, provide a statement suggesting how such Conflict of Interest could be avoided or

mitigated. In order to facilitate such full disclosure, AltaMed requires that such persons annually

complete the Disclosure Form attached as Exhibit A.

Completion of a Disclosure Form does not relieve individuals of the obligation to disclose Interests that

may occur after the annual filing of the Disclosure Form (e.g., with respect to a particular transaction).

AltaMed requires all board members, employees, agents and contractors that have or suspect an

Interest that arises after the annual filing of the Disclosure Form to disclose such Interest to your

manager and/or the Office of Compliance and Risk Management (for employees, agents and

contractors), to the Chairperson of the Board Directors (for board members and the Chief Executive

Officer), or to the Vice-Chairperson (for the Chairperson).

Whether an Interest is disclosed on the annual Disclosure Form or in the interim as indicated above, the

person(s) to whom the disclosure is made shall evaluate the situation to determine whether a Conflict of

Interest exists and if so how to manage such Conflict of Interest, including (1) whether AltaMed can

obtain an equivalent or more advantageous alternative transaction or arrangement from a person or

entity that would not give rise to a Conflict of Interest alternative arrangements; and (2) if such

alternative arrangement is not available, whether the transaction / arrangement is in the best interests

of AltaMed (notwithstanding the conflict) and is fair, reasonable and, as applicable, consistent with the

procurement standards in 45 CFR Part 75.

Failure to Disclose

If there is reasonable cause to believe that a person has failed to disclose an Interest, the person shall be

informed of the basis for such belief and afforded an opportunity to explain the alleged failure to

disclose. If, after hearing the response of the individual who failed to disclose an Interest, and making

such further investigation as may be warranted in the circumstances, AltaMed determines that the

individual has in fact failed to disclose an Interest in accordance with this Code of Conduct, appropriate

Page 12 of 21

corrective and/or disciplinary action shall be taken, consistent with the section on Response to

Violations under the “Our Shared Responsibilities” section of this Code.

Disclosure to Federal Funding Agencies

For all actual and potential Conflicts of Interest involving federal funds, the Chief Executive Officer shall

make disclosures to the appropriate federal awarding agency within thirty (30) calendar days of

discovery of the potential Conflict of Interest and in accordance with the terms and conditions of the

applicable federal award. Such disclosures shall be in writing and sent by email communication and

adhere to the following template:

 Email format: To [Insert Name of Federal Awarding Agency Project Officer or Grants Management

Specialist];

 Insert in subject line: Conflict of Interest Disclosures for Award # ________;

 Extension request for disclosure of Conflict of Interest: Yes___ or No ___;

 Revised requested submission date _____ or N/A;

 Description of the actual or potential Conflict of Interest; and

 Description of AltaMed’s plan to eliminate, mitigate, or otherwise resolve the Conflict of Interest.

Family and Personal Relationship Employment

A personal or family relationship with a co-worker is prohibited when it results in a supervisory

associate/subordinate relationship and/or the appearance of a potential or actual conflict of interests. In

these situations, immediately disclose the matter to your manager and/or Human Resources to evaluate

each situation and take appropriate action.

Employment Obligations

Your primary employment obligation is to AltaMed. Any activities, such as but not limited to a second

job, serving on an external board of directors, or a personal business, must not conflict with your

obligations to AltaMed.

To ensure you avoid a potential conflict, notify your manager and/or Human Resources of outside

employment arrangements evaluate each situation and address potential conflicts with your AltaMed

duties. In most cases, we can develop a mitigation plan to help prevent any actual or perceived conflicts.

In addition, you may not use company time, name, assets or the services of other associates for any

outside activities unless authorized by AltaMed leadership.

Honoraria

Employees, agents or contractors, with permission from their supervisor, are encouraged to participate

as faculty and speakers at education programs and functions. However, any honorarium in excess of

$100 shall be turned over to AltaMed unless the employee, agent or contractor requests paid or unpaid

time off to attend the program or that portion of the program for which the honorarium is paid.

Gifts/Gratuities

Board members, employees, agents and contractors may not solicit or accept gratuities, favors or

anything of value from contractors or potential contractors or vendors of AltaMed, or actual or potential

parties to sub-agreements with AltaMed, in exchange for referrals, clientele, Medicare / Medicaid

services or other monetary benefit (including benefit for private financial gain).

Page 13 of 21

A gift means anything offered directly by or on behalf of an actual or potential contractor or vendor, or

an actual or potential party to sub-agreement, other than promotional materials of little or nominal

value, such as a pen, calendar or other items intended for wide distribution. Gifts include, but are not

limited to, personal gifts, such as sporting goods; household furnishings and liquor; social entertainment

or tickets to sporting events; personal loans or privileges to obtain discounted merchandise and the like.

Any board member, physician, employee, agent or contractor shall decline or return any gift and notify

the Compliance Officer of such a gift.

Free Business Competition

It is AltaMed’s policy to purchase supplies and services in a manner that fosters competition among

sellers in an open marketplace, giving AltaMed and its consumers — both individuals and businesses —

the benefits of lower prices, higher quality products and services, more choices, and greater innovation.

This spirit of free business competition includes conducting all transactions in a manner that supports

transparency and maximum practicality in accordance with AltaMed’s procurement policy and

procedure.

AltaMed will be sensitive to, and seek to avoid, Organizational Conflicts of Interests and non-compliance

practices among contractors. Organizational Conflicts of Interest mean that because of relationships

with a parent company, affiliate, or subsidiary organization, AltaMed is or appears to be unable to be

impartial in conducting a procurement action involving such entity. AltaMed may mitigate

Organizational Conflicts of Interest in the following manner:

 In planning and conducting procurements, no parent company, affiliate, or subsidiary organization

will be permitted access to non-public information related to the procurement transaction. To the

extent that such non-public information is already in possession of the parent company, affiliate,

or subsidiary, such non-public information will be (to the extent not otherwise commercially

sensitive) incorporated into the solicitation.

 In evaluating offers and awarding contracts, AltaMed will not give preferential consideration to

any parent company, affiliate, or subsidiary organization.

 In the event that an Organizational Conflict of Interest, including the appearance of impropriety,

cannot be sufficiently mitigated through the above methods, the parent company, affiliate, or

subsidiary organization may be barred from competing.

Should any situations arise where AltaMed appears to be unable to be impartial in conducting a

procurement action involving a related organization, AltaMed will obtain legal advice and counsel

before proceeding with one or more of the aforementioned approaches.

Consultants who want to bid for a contract with AltaMed are prohibited from drafting the contract’s

specifications, request for proposals and the like. Award will be made to the bidder whose bid is

responsive to the solicitation and most advantageous to AltaMed, budget requirements, and other

factors. AltaMed always retains the right to reject any and all bids when it is in AltaMed’s best interest

to do so.

Page 14 of 21

SAFEGUARDING INFORMATION AND RESOURCES

Protected Health Information (PHI)

AltaMed collects information about the patient medical and behavioral conditions, history, treatments,

and more, known as protected health information (PHI). AltaMed realizes the sensitive nature of PHI

and is committed to maintaining its confidentiality and integrity.

All board members, physicians, employees, agents, contractors and all other representatives of the

organization are expected to adhere to Federal, State, and AltaMed privacy and security laws and

requirements, such as those outlined in the Health Information Portability Accountability Act (HIPAA).

This includes not:

 Releasing or discussing PHI with others unless they have a need to know the information in order to

care for our patients, process payment for services, and/or to manage our healthcare operations.

 Disclosing confidential information that violates the privacy rights of our patients unless required by

law or regulatory agencies.

Physicians, employees, agents, and contractors should always:

 Access the minimum amount of information necessary to do your job.

 Know and follow all laws, policies, and procedures that apply to your job, including restrictions that

apply to you accessing yours, your family member’s, or your friend’s PHI.

 Keep electronic devices password protected and secure.

 Make sure doors to restricted areas where sensitive information is kept are locked.

 Promptly pick up PHI from fax machines and printers.

 Use a privacy screen on your computer monitor if the screen is visible and readable by others.

 Log off of a shared computer or lock your computer before walking away from it so that others

cannot use it with your user identification.

If you violate privacy and security laws, policies, or requirements, you may be individually exposed to

Federal or State Criminal prosecution, fines & penalties, etc., in addition to disciplinary measures.

Confidential Business Information

We have many types of information that are vital to conducting our business. This includes material and

nonpublic information as well as other confidential and proprietary information about our:

 governance, operations, strategies, products, processes, services and financials;

 members, providers, associates, vendors, agents, business partners and government contracts; and

 any other information deemed “confidential” by the Board of Directors or the Chief Executive

Officer.

We must never disclose our confidential and proprietary information to anyone unless authorized to do

so by leadership, company policy, and/or contract when a legitimate business need exists. In addition,

we must never use nonpublic, material, or confidential and proprietary information about external

entities we may have learned in the course of doing business with them for personal gain or for the

benefit of a third party, and without proper authorization and approvals.

Page 15 of 21

Intellectual Property

AltaMed’s Intellectual Property assets contribute to our effective and competitive ability to conduct our

business, grow our company, and achieve our business objectives. These assets include the ideas,

inventions, the “know-how,” designs, software, business information, financial data, trademarks,

copyrights, patents, apps, and all other proprietary information made for AltaMed or made by AltaMed

employees. We respect our intellectual property and that of other companies. Know that anything you

create within the scope of your employment with AltaMed may be considered company intellectual

property.

Use of Company Assets and Resources

We should only use company funds, equipment, and other assets to conduct business, or for other

reasons approved by your manager. Company assets, such as telephone and email, are to be used in a

professional, productive, ethical, and lawful manner. We must not use, sell or dispose of company assets

unless allowed by policy.

Limited personal use of company equipment is allowed as long as your manager approves it and your

personal use:

 does not affect productivity

 does not result in a direct, material cost to the company

 follows applicable company policies and the law

Always keep valuable assets, such as laptops and mobile devices, physically and electronically secure.

 Use company vehicles only as authorized by your supervisor and ensure all policies are followed.

 Let your supervisor know if any of our assets are damaged or in need of repair.

Using Technology Responsibly

Use technology responsibly and in accordance with our policies. While your manager may allow

reasonable personal use of our technology resources, use good judgment. Keep in mind that anything

you create, store, download, send, or receive using AltaMed systems is company property and can be

reviewed by us at any time, as permitted by applicable law and may be disclosed who have a need to

know, including management, law enforcement, or government agencies, without your knowledge or

permission.

When using our technology:

 Never access, store, or transmit anything that’s intimidating, obscene, or discriminatory.

 Use strong passwords and keep passwords safe.

 Never share passwords or access codes with anyone.

 Lock your workstation when stepping away.

 Install security software and updates as directed by AltaMed; do not interfere with automatic

updates.

HEALTHCARE ADVOCACY

Political activities and advocacy efforts intersect, but they are different. The resources available to

support AltaMed’s uninsured and underinsured communities, including those enrolled in Medi-Cal

managed care programs and public grant services, are very dependent on Federal, State, and local

government decisions. Due to the importance and implications of regulatory restrictions, all advocacy

Page 16 of 21

and educational activities are carefully managed and coordinated through AltaMed’s Government

Relations office to ensure compliance with regulatory restrictions.

Advocacy Activities

Advocacy efforts are allowable, within certain limits, and vital to non-profits in order to protect those

limited resources. Raising awareness and education are part of advocacy efforts. This includes mission

driven calls-to-action that may include:

 Contacting your city, state, and federal representatives to explain your mission and share

information about the work that you’re doing.

 Inviting representatives or members of the community to visit an AltaMed site or to engage in

informational sessions about AltaMed, its mission, and the needs of our communities.

 Email or social media campaigns to share information and to promote events, projects, or initiatives.

 Civic engagement activities that educate our employees, patients or members of our community.

 Non-partisan get out the vote efforts.

Only AltaMed’s Government Relations team facilitates advocacy and civic engagement efforts, in

collaboration with our Legal team, to navigate the many related requirements and restrictions.

Political Activities

As a 501(c)(3) charitable organization, AltaMed Health Services Corporation is absolutely prohibited,

under the Internal Revenue Code, “from directly or indirectly participating in, or intervening in, any

political campaign on behalf of (or in opposition to) any candidate for elective public office.

“Contributions to political campaign funds or public statements of position (verbal or written) made on

behalf of the organization in favor of or in opposition to any candidate for public office clearly violate

the prohibition against political campaign activity.

“Certain activities or expenditures may not be prohibited depending on the facts and circumstances.

For example, certain voter education activities (including presenting public forums and publishing voter

education guides) conducted in a non-partisan manner do not constitute prohibited political campaign

activity. In addition, other activities intended to encourage people to participate in the electoral process,

such as voter registration and get-out-the-vote drives, would not be prohibited political campaign

activity if conducted in a non-partisan manner.” [Internal Revenue Service. “The Restriction of Political

Campaign Intervention by Section 501(c)(3) Tax-Exempt Organizations.”]

As such, AltaMed Board Members, employees, physicians, health care professionals, trainees, agents,

board members, volunteers, representatives, contractors, vendors and other persons or companies

working with AltaMed may not engage in political campaigns which suggest that AltaMed supports any

political party or candidate, such as the President, a Senator, or a House Representative. This includes:

• No soliciting, in any manner, financial assistance or subscription for any political party,

candidate, fund, publication or for any other political purpose from AltaMed employees in the

workplace or otherwise in an employment-related setting; AltaMed employees may engage

voluntarily in political activities outside of business hours but must do so with no affiliation or

connection with AltaMed or any of its affiliate entities

• No engaging in political activities at work and/or during business hours.

Page 17 of 21

• No use of AltaMed’s name, facility or resources in connection with political activities.

• No use of federal grant or related funds to support the costs of prohibited lobbying activities

Bribery

Bribes or gratuities involving public officials and the testimony of witnesses are prohibited. Any offense

that directly or indirectly offers, promises, or gives anything of value to any public official or witness, or

a solicits anything of value by a public official or witness may cause, both, the giver and the taker of a

bribe to be sanctioned. AltaMed will immediately dismiss any employee, remove any officer or board

member, and terminate the contract of any contractor found to have offered or accepted a bribe to

secure funding for AltaMed.

Page 18 of 21

CONCLUSION

AltaMed is committed to creating an environment where anyone acting on behalf of the organization

feels comfortable speaking up when there are questions or concerns. When you have an issue or

concern, consult your direct supervisor. If you are unsure of where to go for support, guidance, or help,

reach out to the Office of Compliance and Risk Management or use the Compliance Hotline.

Compliance Hotline

Telephone Number: (888) 418-1398

Web Address: MyComplianceReport.com (ID is ALTA)