Period Report Form

Period Report Form

This is a report of recurring services performed by the KOL.
Personal Info
I am a...*

DoctorFusion Employee
Your Name*

First NameLast Name
Your Email*
example@example.com
Doctor Name*

First NameLast Name
Credentials*
Doctor Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Doctor Email*
example@example.com
Doctor Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Compliance Info
Click Here to Visit NPI Registry
NPI Number*
Primary Taxonomy Code*
If Other, Please Specify*
License Number(s)*
License State(s)*
Primary Facility Name*
Primary Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code

Reporting Info
Engagement Type*
If Other, Please Specify*
Date Completed*

MonthDayYear
Time Spent*
Include Hours Spent on Engagement Only
Fusion Products Supported*
Was Engagement Virtual?*
Fusion Employee(s) Worked With*
If None, Enter NA
Objectives Achieved*
Would You Like to Report a 2nd Engagement?

Yes
Engagement Type (2)*
If Other, Please Specify (2)*
Date Completed (2)*

MonthDayYear
Time Spent (2)*
Include Hours Spent on Engagement Only
Fusion Products Supported (2)*
Was 2nd Engagement Virtual? *
Fusion Employee(s) Worked With (2)*
If None, Enter NA
Objectives Achieved (2)*
Would You Like to Report a 3rd Engagement?

Yes
Engagement Type (3)*
If Other, Please Specify (3)*
Date Completed (3)*

MonthDayYear
Time Spent (3)*
Include Hours Spent on Engagement Only
Fusion Products Supported (3)*
Was 3rd Engagement Virtual? *
Fusion Employee(s) Worked With (3)*
If None, Enter NA
Objectives Achieved (3)*
Would You Like to Report a 4th Engagement?

Yes
Engagement Type (4)*
If Other, Please Specify (4)*
Date Completed (4)*

MonthDayYear
Time Spent (4)*
Include Hours Spent on Engagement Only
Fusion Products Supported (4)*
Was 4th Engagement Virtual? *
Fusion Employee(s) Worked With (4)*
If None, Enter NA
Objectives Achieved (4)*
Would You Like to Report a 5th Engagement?

Yes
Engagement Type (5)*
If Other, Please Specify (5)*
Date Completed (5)*

MonthDayYear
Time Spent (5)*
Include Hours Spent on Engagement Only
Fusion Products Supported (5)*
Was 5th Engagement Virtual? *
Fusion Employee(s) Worked With (5)*
Objectives Achieved (5)*
Would You Like to Report a 6th Engagement?

Yes
Engagement Type (6)*
If Other, Please Specify (6)*
Date Completed (6)*

MonthDayYear
Time Spent (6)*
Include Hours Spent on Engagement Only
Fusion Products Supported (6)*
Was 6th Engagement Virtual? *
Fusion Employee(s) Worked With (6)*
Objectives Achieved (6)*
Feedback/Notes
Supporting Documentation*

Please upload supporting documentation. (Feedback, X-Rays, Clinical Data, Notes, etc.)
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I agree by submitting this form, I, under penalty of perjury, hereby warrant, represent, and attest to the truthfulness, accuracy, and correctness of the above provided information. Furthermore, I agree to indemnify and hold Fusion Orthopedics, and their affiliates, officers, directions, attorneys, agents, employees and representatives harmless for any error, mistake, or omission in the above provided information. Lastly, I understand, and acknowledge that Fusion Orthopedics is permitted to and shall report the above provided information to the Internal Revenue Service and the Centers for Medicare & Medicaid Services (CMS) for compliance with the Sunshine Reporting Act.*

I Agree
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Period Report Form

Personal Info

Compliance Info

Reporting Info