Signature Requirements on Claims: Medicare Patients

1. Patient’s own signature
2. Signature mark (X) if the patient is unable to sign his or her own name because of illiteracy or physical handicap. A witness must sign his name and address next to the mark, as well as give the reason the patient cannot sign, and the relationship to the patient.
3. Patient signature authorizations can be used:
   • Permitting a physician to obtain a lifetime authorization from the beneficiary to submit claims on the patient’s behalf. Indicate "Patients request for payment on file."
   • Permitting a hospital or other provider to obtain authorization effective for a period of confinement, for services furnished on an inpatient basis
   • Permitting a hospital or other providers to obtain a lifetime authorization for outpatient care
   • One-time. Physicians using one-time authorizations should have the patient sign a brief statement substantially as follows:

Name of Beneficiary, Medicare Claim Number
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. _________ for any service furnished to me by that physician. I authorize release to the Centers for Medicare and Medicaid Services and its agents any medical information about me needed to determine the payments for related services.

• A claim submitted for diagnostic tests or test interpretations performed in a facility that has no contact with the patient. Document the signature space "Patient not physically present for services."
• Medicaid patients
• Deceased patients when the physician accepts assignment

1. A provider may obtain a lifetime authorization from the beneficiary to submit assigned and nonassigned claims on the beneficiary’s behalf. Providers submitting claims either electronically or on the CMS-1500 form, must maintain these signatures on file as they are subject to audit verification. If paper claims are submitted, the statement "Signature on file" or "Patient’s request for payment on file" must appear in Item 12 on the CMS-1500 claim form. When claims are submitted electronically, the patient’s signature indicator must be submitted in the appropriate record.
2. A hospital or other provider may obtain a beneficiary authorization, effective for the period of confinement, for the provider to submit assigned and nonassigned claims for services furnished on an inpatient basis
3. A hospital or other provider may obtain a lifetime beneficiary authorization for outpatient care for providers and for the physicians submitting assigned and nonassigned claims
4. A provider who submits a claim for diagnostic tests or test interpretations may sign the claim on behalf of the beneficiary if the beneficiary is not physically present for the services. If paper claims are used, indicate "Patient not physically present for services" in Item 12 of the CMS-1500 claim form. Submit information in the appropriate record for electronically submitted claims. This does not apply to services furnished in a medical facility that is visited by the patient or whose representative visits the patient.
5. If someone other than the Medicare beneficiary signs the claims form, the relationship between the requestor and the beneficiary and the reason the beneficiary was unable to sign must be indicated
6. Signatures of Medicaid patients are not required, since these signatures are obtained by the state agency