Sign on the Dotted Line, Please!

Version 2.1 Hits the Streets

This week our good friends at the premiere EMS law firm in the United States, Page, Wolfberg and Wirth, released the latest version of the patient signature and authorization form which has fast become the compliance standard in the ambulance industry.

Once again, PWW takes the forefront by introducing language embedded within the form that meets the needs for ambulance companies everywhere to ensure compliance with the rules and regulations surrounding the procurement of patient signatures in the field. The form, by the way, can be found on PWW’s website at

Our clients can access the form in the within the Document Management tab in the Common Documents folder within the client portal application.

More Important than Ever

The focus placed on patient signatures has never been more evident. Properly obtaining and preserving a patient or patient representative signature is more important than ever today’s ambulance billing environment.

For one thing, we have begun to see certain Medicare Administrative Contractors (MAC’s) across the nation begin to not recognize “lifetime” signatures. We have warned that this would be coming in this space and other announcements. We know that WPS Medicare and also now, Palmetto GBA MAC’s will no longer recognize lifetime signatures.

Therefore, it’s important within those jurisdictions (and for Railroad Medicare beneficiaries) to obtain a patient signature each and every time a patient is transported whether it be the first or the tenth time in a week.

A Quick Rundown

Let’s quickly look at the form itself and we’ll break down the three main parts and how to properly execute each one.

Section I

This section contains the most important wording of the entire page. The paragraph in this section extends across the entire form and highlighting its purpose we find the patient verifying that the ambulance service was provided to the patient for the incident in question.

The patient also agrees to pay any payment receive directly from an insurance to the ambulance service. Also, by having the patient sign he/she agrees to allow the biller in question to appeal a denied claim on behalf of the ambulance department on scene. The signature also doubles as the acknowledgement of receiving the HIPAA NPP copy.

Only the patient should sign in this area. If the patient makes a legal mark (such as an “X”) then that execution should be witnessed with a signature, making sure to capture the printed name of the signer and his/her address. The only time someone other than the patient signs in this area is if the patient is a minor… then the parent or legal guardian signs in this place.

Section II

This section, along with Section III, is reserved for obtaining a signature on behalf of a patient who is physically or mentally unable to sign.

Upon determining the patient’s inability to sign, then it is appropriate to have the person who agrees to represent the patient sign in this area. Be sure to always print the name of the person signing on behalf of the patient and obtain and record his/her address.

Along with signing, the provider must list on the line provided what injury or illness causes the patient to be unable to sign for himself/herself. This should correlate with the subjective narrative explanation in the Patient Care Report (PCR).

Before you leave this section, also be sure to record the authority of the person by checking off the appropriate at the bottom of the Section.

Section III

Like Section II, this section is also in place for those scenarios when the patient is physically or mentally unable to sign. Once again, as in Section II, please be sure to provide a reason why you observed the patient could not sign and reinforce that reason in the PCR documentation.

This section will now be signed by your or your partner on the run. By signing you are indicating that there was no authorized representative present to sign on behalf of the patient.

The rules require that you also acquire one of two supporting actions or information to go along with your signature.

Either you must obtain the signature of a person at the receiving facility who will agree with your observation that the patient is unable to physically or mentally sign OR you must collect a hospital face sheet or demographic form complete with the time/day stamp on the form noting the calendar date and the time of day you delivered your patient to the receiving facility.

Of course, also be sure to ask the person signing to print his/her name and date the signature. Also be sure to note the name of the facility and the time and date you delivered your patient to that facility.

We leave you with…

Remember… your billing office cannot bill Medicare and in most cases, Medical Assistance without obtaining a signature from the patient.

It’s best to collect a patient or patient representative’s signature from each and every patient you transport, each and every time.

You’re on your way!

Now you are on your way to producing more revenue in a shorter timeframe if you have collected a signature for each run you complete.

If you haven’t been provided with this latest patient signature form and your billing office is still recommending that three-line language mini-paragraph from “back in the day.” Then it’s time to make a change in the form and probably time to take a look at other billing options.

Call us to find out more how you can receive this unparalleled support all the time.

Leave a Reply

Your email address will not be published. Required fields are marked *

Name *