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Patient Signature: A Brief Refresher

May 30, 2017


We’re all familiar with the form of many names.  Some refer to it as a beneficiary signature form, others as a signature and claims submission authorization form (which is what’s actually on the form), and yet for our purposes, we will use another common term, the Assignment of Benefits form (AOB).   There is no official format; however, most organizations utilize the form as you see it here, which is an industry standard.  This is also what Cornerstone recommends.


To better understand the sections and their intended purposes, let’s break them down one at a time.
Section I
To better understand the sections and their intended purposes, let’s break them down one at a time.
Section I


To better understand the sections and their intended purposes, let's break them down one at a time.


Section I




  • Who signs in Section I?
    • The patient
    • If the patient is a minor, the parent or legal guardian
    • If the patient is unable to complete his/her name, but can make a mark, a witness (which can be an ambulance crew member) needs to sign off, at the time the mark was made
Section II



  • Who signs in Section II?
    • First, it’s important to note that this section only applies if the patient is physically or mentally incapable of signing.  If a provider is in this situation, he or she needs to describe why this is. 
    • With this criteria met, an authorized representative may sign.  Authorized representatives include:
      • Beneficiary’s legal guardian
      • Relative or other person who receives social security or other government benefits on behalf of the patient
      • Relative or other person who arranges for the patient’s treatment or exercises 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
Section III



  • Who signs in Section III?
    • It’s important to note that this section only applies if the patient is physically or mentally incapable of signing and no authorized representative as indicated in Section II was available or willing to sign on behalf of the patient at the time of service.  If a provider is in this situation, he or she needs to explain why this is.
    • With this criteria met, the ambulance provider can sign
    • Take note, if the provider is signing:
      • It needs to happen at the time of transport
      • All fields must be completed.  This includes the name and location of receiving facility, along with the time, date, printed name and title of the provider.
      • Also, the provider should have a representative of the receiving facility sign and print his or her name, making sure to include the date, and his or her title. 
      • If no representative of the receiving facility is available or willing to sign, then a secondary form of verification, obtained at a later date but prior to submitting the claim, can be used.  This includes a copy of any of the following:
        • Signed PCR
        • Admission sheet/“Face sheet”
        • Patient’s medical record
        • Hospital or facility log
        • Other acceptable internal facility record


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