Last Modified: 12/27/2019
Location: FL, PR, USVI
Business: Part A, Part B
Q: Where can I find an example of a "signature attestation statement"? Is a specific form required?
A. The Centers for Medicare & Medicaid Services (CMS) requires that any Medicare service provided or ordered must be authenticated by the author -- the one who provided or ordered that service. Certain types of signatures (e.g., illegible signatures, initials) may require the addition of a “signature attestation statement” or a signature log to the documentation to ensure the signature’s authentication. If documentation submitted for medical review does not contain a signature at all, then only a signature attestation will be accepted.
CMS issued
change request (CR) 6698 
, which clarified Medicare fee-for-service signature requirements. According to
CR 6698 , “In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.”
However, CMS neither requires nor instructs providers to use a specific form or format for the attestation statement.
Note: Samples of signature attestation statements (
English 
and
Spanish ) may be found on the First Coast website physician signature requirements simulation.
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
