| Notes: Please submit this template as a Comma Separated Value (CSV) file Recipient = Covered Recipient or Physician Owner or Investor Form of payment must be 1) cash or cash equivalent, 2) in-kind items or services, 3) stock, a stock option, or any other ownership interest, dividend, profit, or other return on investment Nature of payment must be 1) Consulting fee, 2) Compensation for services other than consulting, 3) Honoraria, 4) Gift, 5) Entertainment, 6) Food and beverage, 7) Travel and lodging, 8) Education, 9) Direct Research, 10) Indirect Research, 11) Charitable contribution, 12)Royalty or license, 13) Current or prospective ownership of investment interests, 14) Direct compensation for serving as a faculty or as a speaker for a medical education program, 15) Grant, or 16) Other |
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| Reporting Entity | Recipient Name | Recipient Business street address | Recipient Specialty *physician only | Recipient National Provider Identifier (NPI) *physician only | Amount of Payment (US dollars) | Date of Payment | Form of Payment | Nature of Payment | Name of Associated Drug, Device, Biological, or Medical Supply *if necessary | Entity Paid Name | Physician Owner or Investor (y/n) | Delayed Publication (y/n) |
| Notes: Please submit this template as a Comma Separated Value (CSV) file Owner = Physician Owner or Investor All payments or other tranfers of value provided to physician owners or investors must be reported on the Payment & Transfer of Value tab and designated as that to a physician owner or investor. |
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| Reporting Entity | Recipient Name | Recipient Business street address | Recipient Specialty *physician only | Recipient National Provider Identifier (NPI) *physician only | Interest Held by Immediate Family Member (y/n) | Dollar Amount Invested | Value of Interest | Terms of Interest |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |