Signature requirement samples

Sample signature log

Providers will sometimes include a signature log along with medical record documentation to help reviewers identify the author of the medical record. A signature log lists the typed or printed name of the author associated with initials or the illegible signature in the medical records. A signature log can be included on the actual page where the initials or illegible signature are used, or it can be included with the medical records submission as a separate document.

Sample signature attestation statement 

If signatures are missing or illegible, providers may submit an attestation statement. 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. 

The following is an example of a valid attestation statement that may be used in the event that a provider would choose to submit one. 

“I, _____ [print full name of the physician / practitioner] ___, hereby attest that the medical record entry for _____ [date of service] ___ accurately reflects signatures / notations that I made in my capacity as _____ [insert provider credentials, e.g., M.D.] ___ when I treated / diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Note: At this time, CMS is neither requiring nor instructing providers to use a certain form or format. The above format has not been approved by the Office of Management and Budget (OMB) and therefore is not a mandatory format. 

For additional guidance, refer to the Complying with Medicare signature requirements MLN fact sheet.