HCFA-1500 Box 13 - Insured's or Authorized Person's Signature

On the HCFA-1500 form, Box 13 is used to capture the insured’s or authorized person’s signature, authorizing the payment of medical benefits directly to the provider. This is known as the assignment of benefits and is a standard part of claim processing.

Tip: This box is typically completed with the phrase “SIGNATURE ON FILE”. This indicates that the insured has signed an authorization statement that is kept on file with the provider’s office.

In our example below, Box 13 is filled in with “SIGNATURE ON FILE”.

So far, we've discussed how the assignment of benefits is indicated on the HCFA-1500 form. Now let’s look at how this information is reflected in the X12 837 electronic format.

In the X12 837 transaction, Box 13 maps to the CLM08 element in the 2300 Claim Information Loop. This field is known as the Benefits Assignment Certification Indicator and specifies whether the provider accepts assignment of benefits.

Key X12 837 Details:
  • CLM08: Benefits Assignment Certification Indicator
  • Allowed values: Y (Yes – provider accepts assignment), N (No), W (Not Applicable or patient refuses to assign benefits)
  • For Box 13 with “SIGNATURE ON FILE”, use Y

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

Note: Box 13 maps to CLM08 in the 837 transaction. A value of Y indicates the insured has authorized payment to the provider. The value N is rarely used in electronic claims, and W may be used in special cases.

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
• HCFA-1500 Box 13 - Insured's or Authorized Person's Signature [You are Here]
• 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