2016-698 Emergency Svc - North State Medical Transport - Application for Services Franchise by Ordinance

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Policy on Obtaining Patient Signatures I. PATIENT SIGNATURES A. Medical Transport Personnel are responsible for obtaining the patient's signature on the Ambulance Billing/Privacy Acknowledgment Signature Statement Form. B. If a patient is unable to sign the Signature Statement Form because he or she is illiterate or handicapped, a signature by mark (e.g. X) of the patient is valid. The mark must be witnessed by a third party whose name and signature are noted on the Signature Form. If no third party is available, an NSMT crew member may witness the signature, and must note his/her name. C. If the patient is physically or mentally unable to sign, the crew must attempt to obtain the signature of a representative. The representative can include a legal representative (e.g., guardian), relative or other person who arranges the patient's treatment or manages the patient's affairs. The representative must state their relationship to the patient. In addition to the foregoing, the crew member or the representative must document the specific medical/mental condition that prevents the patient from signing. This condition must be supported in the documentation on the PCR. D. if the patient is physically or mentally unable to sign, and there is no representative, as listed in section I.C. above, available and willing to do so, the PCR must contain: 1. Documentation on the PCR Signature Statement that at the time of the transport the patient was physically or mentally unable to sign and that no representative was present or willing to sign on behalf of the patient (NOTE: documentation on the PCR should support the reason utilized on the PCR Signature Statement for the patient's inability to sign); 2. Signature of the crew member; and 3. A signed statement at the time of transport from a sending or receiving facility representative which lists the name and location of the facility and the date and time of the transport. This infoimation may be contained within the PCR or in a separate attachment. E. If the patient is physically or mentally unable to sign, and there is no representative (a representative listed in section I.C. above or a facility representative in the Signature Statement available to sign, the Field Provider may obtain: f 1. A hospital or facility face sheet, hospital or facility log, or other internal facility record indicating that the beneficiary was received. These documents must be on facility forms and do not require a signature. F. If the patient is capable of signing the PCR but refuses to do so, the Field Provider should explain that the signature is necessary to bill Medicare or certain other payors for the service, and if NSMT does not have a signature the patient or family may have to pay the entire amount of NSMT's charges (instead of just being responsible for any co-payment and deductible amount). If the patient still refuses to sign, the Field Provider should document "Patient capable of signing but refuses to do so." II. ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE ' . An Advance Beneficiary Notice of Non-coverage (ABN) notifies patients that NSMT believes the service provided may not be fully covered by Medicare because it is not "reasonable and necessary" under Section 45