TJO SUNSHINE ACT TRACKING FORM
Distributor/Territory Name
Reporting Month:
Date
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Month
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Day
Year
Date
Physician Name
NPI Number*
* NPI Number can be found at www.npinumberlookup.org
No Expenses This Month
I had no Sunshine Act reporting expenses this month
Amount
^ Unless an individual expense, calculate 'Amount' by dividing total cost by number of attendees.
Description of Payment
Consulting Fees
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Submit
TOTAL JOINT ORTHOPEDICS
MISSION-DRIVEN™
1567 East Stratford Ave.
Salt Lake City, Utah 84106
o. 888.890.0102 f. 801.486.6117 sales@tjoinc.com
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