Hoffman Estates Fire Department Ambulance Transport Guidelines PDF

HOFFMAN ESTATES FIRE DEPARTMENT STANDARD OPERATING GUIDELINES SOG Category & Identification Number: EFFECTIVE DATE: OPERATIONAL GUIDELINES – 018 January 1, 2022 NIMS COMPLIANT SOG Title: Patient Signature...

HOFFMAN ESTATES FIRE DEPARTMENT STANDARD OPERATING GUIDELINES SOG Category & Identification Number: EFFECTIVE DATE: OPERATIONAL GUIDELINES – 018 January 1, 2022 NIMS COMPLIANT SOG Title: Patient Signature Requirement for Revision: Ambulance Transports 1 APPROVED BY: NUMBER OF PAGES: Re-evaluation Date: Alan Wax January 1, 2024 Fire Chief 2 PURPOSE Compliance with Medicare 42 CFR § 424.36 - Signature requirements for ambulance billing. DEFINITIONS CFR – Code of Federal Regulations ePCR – Electronic Patient Care Report Patient Representative or Guardian - (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. POLICY It is required that Hoffman Estates Fire Department (HEFD) personnel obtain a beneficiary (patient) signature from all patients transported to a medical facility and the patient will receive a bill for service so that insurance benefits can be assigned to the Village of Hoffman Estates. 1 PROCEDURE Members of the Hoffman Estates Fire Department are required to obtain a signature from the Patient (beneficiary), Patient Representative, or Hospital/Receiving Agent to authorize a provider or supplier to submit a claim to Medicare for specified services furnished to the beneficiary. Department members can obtain a signature within the “Signature” section provided in ImageTrend on the ePCR. All attempts should be made to have the patient sign their own claim. The patient is required to sign unless they are deceased, physically or mentally incapable of signing. If the patient is physically or mentally unable to sign at the time of service, a signature must be obtained by an “Patient Representative or Guardian.” If there is no Patient Representative or Guardian present, then the Hospital/Receiving Agent, typically, but not necessarily, the Patient’s nurse, may sign on the Patient’s behalf. The ambulance crew is authorized to sign on the Patient’s behalf only if none of the aforementioned individuals were available or willing to sign the claim. A reason must be selected when gathering a signature for a claim. When the Patient or Patient Representative signs the claim, “Release for Billing” must be selected in the “Signature Reason” dropdown box. If the Hospital/Receiving Agent or EMS Crew Member signs the claim, “Billing/HIPAA Acknowledgement” must be selected in the “Signature Reason” dropdown box. All persons signing shall have their first and last names documented along with the time stamp of their endorsement. EXCEPTIONS REFERENCES 42 CFR § 424.36 - Signature requirements End of Document 2