Item 11dLeave blank. Not required by Medicare.Item 12Patient’s or Authorized Person’s SignatureThe patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alphanumeric date (e.g., January 1, 2006) 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, “General Billing Requirements” 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, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless thepatient or the patient’s representative revokes this arrangement.
Instructions on how to fill out the CMS 1500 Form 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. Item 13Medigap Benefits, Insured’s/Authorized Person’s SignatureThe signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked. NOTE:This can be Signature on File and/or a computer generated signature. Item 14Date of Current Illness/Injury/Pregnancy•For current illness, injury, or pregnancy, enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date. •For chiropractic services, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of x-ray (if used to demonstrate subluxation)in item 19. Item 15Leave blank. Not required by Medicare.Item 16Dates Patient Unable to Work in Current OccupationIf the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when thepatient is unable to work.
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- Winter '17
- Postal code, item, National Provider Identifier