Magellan MFLC Program Procedure
Procedure Name: MFLC/Private Practitioner
Avoidance of Conflict of Interest Attestation
Operational Owner/Submitted By: Joyce Trzoniec
Effective Date: 04/24/13
Last Review Date:
Page 1 of 1.
Functional Area: Compliance
Review Interval:
Operational Scope: MFLC Counseling
NAME(S) OF MAGELLAN POLICY & STANDARD(S) TIED TO:
 Magellan Policy: “Conflicts of Interest,” (COM.1913.01)
 MFLC Procedure: “Reporting, Investigating, and Tracking Potential Conflicts of Interest (PCOI)”
PURPOSE: To describe procedures for Magellan MFLC rotational employee-practitioners to indicate whether or not
they have intentions to maintain a private practice contemporaneously with employment as an
MFLC counselor, and if so, formally agree to adhere to specific standards of conduct to avoid
conflicts of interest or appearances of conflicts of interest in connection with private practice.
PROCEDURE:
I.
II.
III.
IV.
V.
All MFLC Rotational employee-practitioners must disclose their Magellan network status and any
independent or group practice affiliations to their MFLC regional supervisor.
All MFLC Rotational employee-practitioners must disclose whether or not they intend to maintain a
private practice while rendering MFLC counseling services by completing an “MFLC/Private Practitioner
Avoidance of Conflict of Interest Attestation” form.
 This form is contained in the orientation packet distributed upon hire (electronic or hard copy).
The completed/signed form shall be returned with other required signed forms during the
Magellan orientation process.
 If an MFLC Rotational employee-practitioner begins to provide services through private practice
after the Magellan orientation process, the form shall be completed at that time. The form is
located in the Quality and Compliance section of the MFLC MagNet site.
Completed/signed forms are maintained in the MFLC rotational employee-practitioners’ personnel files.
Magellan Rotational employee-practitioners discuss potential conflicts of interest and/or the appearance of
such conflicts at least annually with their supervisor as an aspect of job performance.
Magellan employee-practitioners follow the Magellan Procedure, “Conflicts of Interest,” (COM.1913.01)
to identify and report all potential conflicts of interests.
ASSOCIATED FORMS, FLOWS, ATTACHMENTS:
MFLC/Private Practitioner Avoidance of Conflict of Interest Attestation
MFLC Counselor
Private Practice Avoidance of Conflict of Interest Attestation
I, _________________________, am employed by Magellan as an MFLC counselor.
[please print]
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I understand that the MFLC program prohibits conflicts of interest and that I
must avoid even the appearance of a conflict of interest.

I understand that conflict of interest includes any conduct or omission on my part
that takes advantage of my position as an MFLC counselor to attain personal
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financial gain.
Please select one of the following:
I do not intend to maintain a private practice contemporaneously with my
employment as an MFLC counselor. If I choose at a future date to maintain a private
practice contemporaneously with my employment as an MFLC counselor, I will notify
my Regional Supervisor and complete a new “Private Practice Avoidance of Conflict of
Interest Attestation.”
I intend to maintain a private practice contemporaneously with my employment as
an MFLC counselor. I agree to adhere to the following standards of conduct in
connection with my private practice:
o I will not market or otherwise promote my private practice while on duty as
an MFLC counselor, including without limitation, doing any of the following
while on a military base or other site for delivery of MFLC services:
distribution of my private practice business card, distribution of any
marketing materials for my private practice, unsolicited disclosure of
information about my private practice, or furnishing the telephone number,
email address, or web address for my private practice.
o I will refrain from identifying myself as an MFLC counselor on my private
practice stationery or business card or on any website, blog, directory, or
advertising that relates to or refers to my private practice, including without
limitation making any representations in connection with my private
practice to the effect that the MFLC program in any way endorses or
recommends my private practice services.
o I will not refer any service member or military family member whom I
counsel in any way in my role as an MFLC counselor to myself or to any
counselor, therapist, or mental health or substance abuse program in which
I have a financial interest, or to the private practice of another MFLC
counselor. I will not recommend or suggest, directly or indirectly, that any
such service member or military family member obtain services from me or
any counselor, therapist, or mental health or substance abuse program in
which I have a financial interest, or from the private practice of another
MFLC counselor.
o I will not while on duty as an MFLC counselor solicit any service member or
military family member to obtain services from me in my private practice or
from any counselor, therapist, or mental health or substance abuse program
in which I have a financial interest.
o Whenever I determine that my private practice client is a service member or
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military family member not referred to me from the MFLC program or the
Military OneSource (MOS) program, I will inform the client that nonmedical counseling services are available without charge through the MFLC
program and the MOS program. If the client chooses to obtain non-medical
counseling through either of those programs, I will, without charge,
facilitate a referral or connection to MFLC services by providing contact
information and/or calling on behalf of the client.
o If any private practice client who is a service member or military service
member recognizes that I am an MFLC counselor, I will ensure that the
client understands that he/she is seeing me in my private practice; that I,
and not the MFLC program, will be solely responsible for the services I
provide; and that the client and any health insurance to which he/she is
eligible will have financial responsibility for my services.
o I will not allow my private practice to interfere with my responsibilities as
an MFLC counselor. In the event of a conflict between my private practice
and my obligations as an MFLC counselor, I will reschedule my private
practice clients or take other appropriate action to ensure that my services
as an MFLC counselor can be provided without impairment.
o I understand that the following would not usually be considered a conflict of
interest:
 Acceptance of a referral from another program for the military
community, such as MOS, a military treatment facility, CHAMPUS, or a
Family Advocacy Center.
 Solicitation of individuals for counseling services when I am off duty
within the parameters set by my professional code of ethics, regardless of
their status as service members or military family members.
 Referral of a service member or military family member to the private
practice of another MFLC counselor based on a referral list from the
MOS program, provided I do not have a financial interest in that MFLC
counselor’s private practice.
 Identification of my status as an MFLC counselor, as relevant, on my
resume and on any job application, background check questionnaire,
insurance applications, and similar documents.
 Acceptance as a client of any service member or military family member
through professional referrals, word-of-mouth, or marketing or
advertising that does not violate any of the commitments in this
statement.
 Using in my private practice counseling or presentations in the
community knowledge of issues and stressors related to military life
gained through my experience as an MFLC counselor.
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I will discuss potential conflicts of interest and/or the appearance of such conflicts
at least annually with my Regional Supervisor as an aspect of job performance.
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If I should have difficulty at anytime in determining whether a particular set of
circumstances would result in a conflict of interest, I will consult with my Regional
Supervisor for direction.
________________________________
MFLC counselor signature
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Date: __________________