HCO & HCP Spend Tracking Form

    If you did have payments or transfers of value where the primary reason for the payment or value transfer is in connection with TMC product*, check this box and complete the rest of this form.

    *In general, if TMC product is discussed for over 50 percent of the total time spent discussing products with the HCP, then the ISA’s primary reason for the payment or value transfer is in connection with the TMC product.

    Independent Sales Agency Name:*




    IMPORTANT: In addition to this form, a separate completed sign-in sheet is required for any activity where a meal is provided.  Each attendee (including you and any other involved sales agents) must be recorded.

    Maximum upload file size: 5 MB.

    Attach sign-in sheet:

    Business Purpose:

    Date of Activity:

    Location of Activity:

    Recipient's Full Name:

    If physician, affiliated institution:

    National Provider ID (NPI#):

    Recipient's Business Address:

    Description of TMC business purpose discussed:

    Nature of Payment (select the applicable items):

    MealsTravel (including ground transportation)In-Service**Education (journal reprints and medical textbooks)Charitable Contributions**Consulting Fees**Direct Compensation for speaking/serving as faculty for a Medical Education ProgramEducational GrantsExhibitsResearch**Royalty or License PaymentsPhysician Ownership or Investment Interests

    If Physician Ownership or Investment Interests is selected above, total value of payment: $

    Form of Payment (ex. cash, credit, etc.):

    Additional Comments/Information:

    **Note: Please attach all documents related to activity (e.g., receipts, invoices, etc.).

    Maximum upload file size: 5 MB.

    Attach Related Document 1

    Attach Related Document 2

    Attach Related Document 3

    Attach Related Document 4

    TERMS OF ACCEPTANCE AND SIGNATURE: I, the Independent Sales Agent submitting this form, warrant the truthfulness of the information provided in this form.

    I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

    Electronic Signature (please type your first and last name):*