HCFA-1500 Box 12 - Patient's or Authorized Person's Signature

On the HCFA-1500 form, Box 12 is used to capture the patient's or authorized person's signature, authorizing the release of medical information necessary to process the claim. This signature also permits the provider to submit the claim on the patient’s behalf.

Tip: This box is typically populated with the phrase “SIGNATURE ON FILE” along with the current date in MMDDYYYY format. For example, 'SIGNATURE ON FILE' and '07302025' indicate the provider has a signed authorization on record as of July 30, 2025.

In our example below, Box 12 is filled in with 'SIGNATURE ON FILE' and the date '07302025'.

So far, we've discussed how the authorization signature is captured on the HCFA-1500 form. Now let’s look at how this information is translated in the X12 837 electronic format.

In the X12 837 transaction, Box 12 maps to the CLM09 element in the 2300 Claim Information Loop. This field is known as the Release of Information Code and indicates whether the provider has a signed release on file.

Key X12 837 Details:
  • CLM09: Release of Information Code
  • Allowed values: Y (Yes – signed release on file), I (Informed consent obtained)
  • For Box 12 with "Signature on File", use Y

Sample 837P (5010/4010) – 2300 Claim Information

Note: Box 12 maps to CLM09 in the 837 transaction. A value of Y indicates the provider has signed authorization to release information for this claim. The value I is only used in limited cases where informed consent is required but no signature is collected.

For additional information on the X12 837 standard, please refer to the official implementation guides published by X12.

HCFA-1500 Form Box Locations

• HCFA-1500 Box 0 - Carrier Block
• HCFA-1500 Box 1 - Insurance Type
• HCFA-1500 Box 1a - Insured's ID Number
• HCFA-1500 Box 2 - Patient's Name
• HCFA-1500 Box 3 - Patient's Birth Date and Sex
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address
• HCFA-1500 Box 6 - Patient Relationship to Insured
• HCFA-1500 Box 7 - Insured's Address
• HCFA-1500 Box 8 - Reserved For NUCC Use
• HCFA-1500 Box 9 - Other Insured's Name
• HCFA-1500 Box 9a - Other Insured's Policy or Group Number
• HCFA-1500 Box 9b - Reserved For NUCC Use
• HCFA-1500 Box 9c - Reserved For NUCC Use
• HCFA-1500 Box 9d - Insurance Plan Name or Program Name
• HCFA-1500 Box 10 - Is Patient's Condition Related To
• HCFA-1500 Box 10d - Claim Codes
• HCFA-1500 Box 11 - Insured's Policy Group or FECA Number
• HCFA-1500 Box 11a - Insured's Date of Birth and Sex
• HCFA-1500 Box 11b - Other Claim ID
• HCFA-1500 Box 11c - Insurance Plan Name or Program Name
• HCFA-1500 Box 11d - Is There Another Health Plan
• HCFA-1500 Box 12 - Patient's or Authorized Person's Signature [You are Here]
• HCFA-1500 Box 13 - Insured's or Authorized Person's Signature
• HCFA-1500 Box 14 - Date of Current Illness, Injury, Pregnancy (LMP)
• HCFA-1500 Box 15 - Other Date
• HCFA-1500 Box 16 - Dates Patient Unable to Work in Current Occupation
• HCFA-1500 Box 17 - Name of Referring Provider or Other Source
• HCFA-1500 Box 17a - Other ID
• HCFA-1500 Box 17b - NPI
• HCFA-1500 Box 18 - Hospitalization Dates Related to Current Services
• HCFA-1500 Box 19 - Additional Claim Information
• HCFA-1500 Box 20 - Outside Lab Charges

Grab a sample of the HCFA-1500 claim form here - HCFA 02/12 Claim Form