Patient signature field – CMS 1500 Item 12

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 alphanumeric date (e.g., January 1, 2008) 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 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.