Field 12 - Patient’s or Authorized Person’s Signature
The “Patient’s or Authorized Person’s Signature” indicates there is an authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim.
NUCC INSTRUCTIONS: Enter “Signature on File,” “SOF,” or legal signature. When legal signature, enter date signed in 6-digit (MM|DD|YY) or 8-digit format (MM|DD|YYYY) format. If there is no signature on file, leave blank or enter “No Signature on File.”
MEDICARE INSTRUCTIONS - The patient or authorized
representative must sign and enter either a 6-digit date (MM | DD | YY),
8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998)
unless the signature is on file. In lieu of signing the claim, the patient may
sign a statement to be retained in the provider, physician, or supplier file in
accordance with Chapter 1, “General Billing Requirements.” If the patient is
physically or mentally unable to sign, a representative specified in chapter 1,
may sign on the patient's behalf. In this event, the statement's signature line
must indicate the patient's name followed by “by” the representative's name,
relationship to the patient, and the reason the patient cannot sign. The
authorization is effective indefinitely unless the patient or the patient's
representative revokes this arrangement.
NOTE: This can be "Signature on File" and/or a computer generated
signature.
The patient's signature authorizes release of medical information necessary to
process the claim. It also authorizes payment of benefits to the provider of
service or supplier when the provider of service or supplier accepts assignment
on the claim.
Signature by Mark (X) - When an illiterate or physically handicapped enrollee
signs by mark, a witness must enter his/her name and address next to the mark.
Related Articles
Field 13 - Insured’s or Authorized Person’s Signature
The “Insured’s or Authorized Person’s Signature” indicates that there is a signature on file authorizing payment of medical benefits. NUCC INSTRUCTIONS: Enter “Signature on File,” “SOF,” or legal signature. If there is no signature on file, leave ...Field 2 - Patient's Name
Field 2 on the CMS 1500 claim form is for the Patient's Name. The “Patient’s Name” is the name of the person who received the treatment or supplies. NUCC INSTRUCTIONS: Enter the patient’s full last name, first name, and middle initial. If the patient ...FIELD 26- Patient’s Account No.
The “Patient’s Account No.” is the identifier assigned by the provider. NUCC INSTRUCTIONS: Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system. Do not enter hyphens with numbers. Enter numbers left ...Field 3 - Patient's Birth Date
Field 3, the “Patient’s Birth Date, Sex” is information that will identify the patient and it distinguishes persons with similar names. NUCC INSTRUCTIONS: Enter the patient’s 8-digit birth date (MM | DD | YYYY). Enter an X in the correct box to ...FIELD 31- Signature of Physician or Supplier Including Degrees or Credentials
The “Signature of the Physician or Supplier Including Degrees or Credentials” refers to the authorized or accountable person and the degree, credentials, or title. NUCC INSTRUCTIONS: “Signature of Physician or Supplier Including Degrees or ...