Sign on the Dotted Line! Properly Obtaining Patient Signatures in the Field.

By Chuck Humphrey, B.A., EMT-B, CAC, CACO, CADS *


Can you boast a 100% signature rate?

In my 37 years of EMS field experience, I can boast a 100% patient signature success rate…NOT!  It’s a joke that circulates between my EMS billing peers and me. I’d love to lay claim to such a statement, but alas like probably most if not all of you; I cannot.

Sign On The Dotted Line Blog Post image showing a person signing a form on a tablet using their finger

So, why is it important that we closely follow the rules surrounding collecting a patient signature in the field and what is the drill-down when the patient isn’t able or willing to sign?  

Let’s break it all down.


Why must we obtain a patient signature? For most of us, the EMS agencies where we serve have developed SOPs and best practices to outright mandate EMS field personnel to obtain a signature.

Much of the “why” is a direct tie to the Medicare rules. Simply stated, in the eyes of the Centers for Medicare and Medicaid Services (CMS), obtaining a patient signature is a safeguard of the Medicare fraud and abuse initiatives. The theory is that the only way to confirm that an EMS transport, billable to Medicare, was completed is to obtain a signature from the patient who was transported.

Without a patient signature or a patient’s representative signature, billing is prohibited for ambulance transportation to Medicare and, in almost all cases, Medicaid too. As such, in order to keep much-needed reimbursement dollars flowing, the responsibility for signature procurement trickles down to the people who interact with the patients- and that means YOU the EMS field provider.


First and foremost, it should be the number-one goal of an EMS provider when considering the most appropriate time to procure the signature (i.e. after the patient has been appropriately treated and a transport plan is in place) to obtain the actual signature from the patient, himself, or herself.

The most effective signature is the patient signature. The only acceptable reason to not obtain the patient’s signature is when you find the patient (and document as such) physically and/or mentally unable to sign.

Determining if the patient is physically and/or mentally unable to sign will include a vetting process to include these simple questions…

  • Is the patient conscious, alert and oriented to understand the permission statement I am asking him/her to sign?
  • Does the patient have use of his/her dominant arm and hand in order to sign?
  • Can my patient sign without risking interrupting important life-sustaining interventions?

If the answer to any of the above questions is a “no”, then obviously the field provider will be unable to obtain the patient’s signature.

Now what?

Guardian, Relative, Other Person or Representative

When the patient is unable to sign, EMS personnel can then drill down to decide if it is possible or not to obtain a signature from someone who will represent the patient. The rules allow for a person, other than the patient, to sign in the Medicare scenario. CMS allows the person who is willing to sign on behalf of the patient to be defined using one of the following definitions…

  • Patient’s legal guardian.
  • Relative or other person who received social security or other governmental benefits on behalf of the patient.
  • Relative or other person who arranges for the patient’s treatment or exercised other responsibility for the patient’s affairs.
  • Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient.

The person signing on behalf of the patient agrees that he/she fits one of the above definitions listed above.  

Plan Z!

What if your patient is physically and/or mentally unable to sign and there is no other person available or willing to sign as the patient’s representative? You know that leaving the signature area blank is just not an option (be ready to answer to your supervisor!) …so, what can you do?

Luckily, there is a “Plan Z”, call it the nuclear option if you will. This last-ditch, final option is to invoke the ambulance crew/receiving facility combo.

A member of the transporting EMS crew can sign, attesting to the fact that the patient was physically and/or mentally incapable of signing and laying claim to the reality that there was no one person willing to sign on behalf of the patient.

However, if you choose this option, there is a second requirement to enable your billing office to submit a claim in order to collect reimbursement for this EMS incident.

The second part includes one of two options.  

The best option is to also obtain a signature from a facility representative located at the receiving facility/transport destination.  That facility representative is basically agreeing with you, in writing, that the patient is- as you have indicated- physically and/or mentally incapable to signing. If you are going to use Plan Z, this is the best co-requirement.

There is also the ability for you or your partner to sign and then obtain a written record time and day stamped with the date and time you presented the patient to the receiving facility and this in most cases would mean procuring a hospital “face sheet” to accompany the paperwork you file with your patient care report.

And then there is COVID…

One final loophole for signatures, has been in place since early 2020. We can call this the “COVID loophole” which allowed for the EMS field provider to document a patient’s verbal consent to which one of the transporting EMS crew members can then sign to attest to the verbal consent. This was allowed for those scenarios where the crew on the call were assumed to be outfitted in full personal protection equipment (PPE) and not wishing to risk infection themselves nor contamination of their equipment (i.e., mobile tablets, writing implements, etc.) due to the patient’s exhibiting COVID-19 symptoms or presenting with a positive COVID-19 test result.

This loophole has been allowed until the Public Health Emergency (PHE) expires which, as of this writing, we have just learned that The White House will call a halt to the declared Federal PHE beginning on May 11, 2023. On that date and thereafter, the verbal consent option will expire and can no longer be used in lieu of an actual signature.


Of course, all the above implies that your EMS agency is using patient signature disclaimer verbiage that fits the CMS rules and regulations pertaining to patient signature procurement. Today’s the day to review that verbiage on paper, digitally or both to ensure that those signatures are attached to the correct permission and assignment statements.


*Chuck Humphrey is an independent contractor who spent 25 years in the EMS revenue cycle management industry, prior to his retirement from Quick Med Claims. In addition to holding active EMT credentials in Pennsylvania, he is also a Certified Ambulance Coder, Certified Ambulance Compliance Officer, and Certified Ambulance Documentation Specialist via the National Academy of Ambulance Compliance. Humphrey is a periodic guest contributor to the QMC blog and podcast space. 


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