EMS Signatures | Part 1: Patient Signatures

Obtaining signatures can be the bane of many EMS providers’ existence. The task is both simple and difficult. From patients who aren’t willing to sign anything, to the many other responsibilities of documentation and providing care that seem infinitely more important, providers can treat signatures as an afterthought. And it shows! In a recent Palmetto Post-Payment Service-Specific Probe Review, lack of a proper Beneficiary or Authorized Representative Signature was a top denial reason in all four states under review. With this article we hope to aim a spotlight on a common denial/refund reason that can often go under the radar compared to topics like medical necessity.

This article is the first part in our series on signatures in EMS and will focus on the beneficiary or authorized representative signature (the AOB). We’ll break down the importance of the signature, explain the requirements, and go over some examples and common situations related to signatures. Our hope is that after reading this article you’ll understand the importance of the AOB signature and will work to ensure each one is obtained properly at your service or in your own work going forward.


What’s the Point?

You’ve looked at numerous AOB forms a day, but do you know what it actually says? The form does a lot of work in a short space. First, Medicare requires the AOB signature to be on file prior to submitting the claim to Medicare. Additionally, the statement associated with the AOB also does things like acknowledges the patient is financially responsible for the transport, allows the service to receive payment on behalf of the patient, appeal the claim if it gets denied, and otherwise use the information associated with the transport to adjudicate the claim on the patient’s behalf. Finally, this form usually includes an acknowledgment of receipt of the service’s Notice of Privacy Practices (NPP), something required under HIPAA. Taken together, this simple signature is a key part of the ambulance service’s documentation, and it should be treated with that importance.


What’s Required?

Under 42 CFR § 424.36, the beneficiary’s own signature is required, unless they’re deceased, or an exception applies. The exceptions to the patient’s personal signature apply when the patient is mentally or physically incapable of signing the AOB form. Examples of being incapable of signing include unconsciousness, mental incapacitation including being altered by drugs or alcohol, weakness, pain, or restraint. When documenting that the patient is incapable of signing, it’s important that their condition is clearly documented in the proper field on the AOB form and that the other documentation in the PCR supports the reason given on the AOB.

The exceptions to the patient signing for themselves are as follows: First, if the patient is incapable, the crew must look for someone who qualifies as an authorized representative to sign on the patient’s behalf. Second, if the patient is incapable of signing and the crew is either unable to locate an authorized representative to sign, or that person is present but is unwilling to sign, then the crew may sign for the patient and obtain a contemporaneous signature from the receiving facility to support that the patient was actually received by the facility on that date.

We recommend using the PWW AOB form from their free form library. This form clearly breaks down the signature requirements by section, with Section I being for the patient’s signature, Section II being for an authorized representative’s signature, and Section III for the EMS provider and facility signature.


Who is Authorized to Sign for the Patient?

The following individuals may sign on behalf of the patient when the patient is physically or mentally incapable of signing:

(1) The beneficiary’s legal guardian.

(2) A relative or other person who receives social security or other governmental benefits on the beneficiary’s behalf.

(3) A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his or her affairs.

(4) A representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services, or assistance to the beneficiary.



As a quick recap, the crew should first get the patient to sign in Section I of the AOB. If the patient is physically or mentally incapable of signing, the crew should attempt to obtain a signature from someone authorized in Section II. Finally, if the patient is incapable and no one is available to sign Section II, then the crew and a representative of the receiving facility may sign Section III.


Common Problems

Now that you understand why the beneficiary signature is important and the basic requirements for obtaining the signatures on the AOB, lets review some common scenarios that may give providers pause.

  • The patient is a minor. One scenario that trips providers up is when the patient is an unemancipated minor. As with any contract, minors cannot sign, however their parent or legal guardian stands in for them and may sign Section I. Sometimes providers may think the parent or legal guardian should sign Section II, but that is only used for adult patients who are mentally or physically unable to sign.
  • The patient has a history of dementia or confusion, but at the time of transport and signing, the patient is fully A&O x4 and GCS 15. We often see providers sign Section II or III and state that the patient has dementia. However, if there aren’t any documented mental incapacities at the time of signing, then the patient should sign Section I. Remember, the incapacity must be supported in the PCR for that transport.
  • Return trips to the nursing home. Another common scenario is a return trip from a hospital to the nursing home. In some cases where the patient is incapable of signing, the crew signs Section III. However, if the patient is a resident of the nursing home, then the nursing home staff can serve as an authorized signer under option 4 above. This is important to remember because the AOB signature process works in the order of the best possible signature, meaning if you can obtain a Section II signature, you should not get a Section III signature instead. We recommend always going down the list from Section I, to each option in Section II, then finally to Section III.
  • What if the patient is capable of signing but refuses? You cannot force the patient to sign the AOB and their refusal to sign does not count as being mentally or physically unable to sign. In this scenario, do not obtain an alternative signature in the AOB. You may inform the patient that without signing the AOB, they will be directly responsible for paying the transport, because your service cannot bill Medicare without their signature. If the patient still refuses, you may document that the patient refused to sign. The AOB signature requirement can be met after the transport, meaning if the patient refused to sign, your service may obtain the patient’s signature later and then submit the claim to Medicare. Therefore, we recommend sending the patient a bill for the transport along with a copy of the AOB for them to sign and return to you with instructions stating that their signature is required to bill Medicare.
  • What if an authorized person is present but refuses to sign Section II? Unlike a patient who is capable but refuses to sign, an authorized representative is not required to sign. If for some reason they are present but refuse to sign, they may be treated as if they are not available, and the crew may then sign Section III.


Good Luck!

Signatures are a key requirement for billing Medicare and it’s important to get them right to avoid future headaches. We hope this article is helpful in laying out why the AOB is important, how it works, and some solutions to common problems with signatures. Please reach out to us if you have any further questions about the AOB or signatures in general and be on the look-out for our next article in our EMS Signatures Series!