CMS 1500 – BLOCK 12 PATIENT OR AUTHORIZED PERSON’S SIGNATURE
The patient or an authorized representative must sign and enter the six – digit date (MMDDYY) for this block 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. If the patient is physically or mentally unable to sign, a representative 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 form. The signature on file authorization is effective indefinitely unless patient or the patient’s representative revokes the arrangement.
The patient’s signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.
Signature By Mark (X) – When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.
Signature on File Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary’s behalf.
BLOCK 13 INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
BLOCK 14 DATE OF CURRENT ILLNESS
the six – digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six – digit date (MMDDYY) of the initiation of the course of treatment and enter the six – digit date (MMDDYY) x-ray date in block 19
.Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.Completion of this field is required for all chiropractic services; conditional for other services.
BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS
blank. Not required by Medicare.
BLOCK 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
the six – digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage.Completion of this field is conditional for disability information.
BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Referring Physician – A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician – A physician who orders nonphysician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.All claims for Medicare covered services and items that are the result of a physician’s order or referral must include the ordering/referring physician’s name and Unique Physician Identification Number (UPIN) and National provider number (NPI)
BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
Enter the six – digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Completion of this field is conditional for medical services related to hospitalization.
BLOCK 19 RESERVED FOR LOCAL USE
BLOCK 20 OUTSIDE LAB
Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the “YES” block is checked. A “YES” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “NO” check indicates that “no purchased tests are included on the claim”. When “YES” is annotated, block 32 must be completed.
BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Enter the patient’s diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.
All narrative diagnosis codes must be submitted on an attachment.
BLOCK 22 MEDICAID RESUBMISSION
Leave blank. Not required by Medicare.
BLOCK 23 PRIOR AUTHORIZATION NUMBER
Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
Enter the Investigational Device Exemption (IDE) number for those clinical trial procedures requiring IDE approval.
For paper claims only, enter the ten – digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.
Completion of this field is conditional the situations above
