Company Edit, Orders, Electronic

Last Electronic Submission Number Used

The last electronic submission number used, which will be the basis for the next electronic submission number.

Customer Signature Source (CSMBP)

C	Signed HCFA-1500 claim form on file.
S	Signed signature authorization for block 12 only on file.
M	Signed signature authorization for block 13 only on file.
B	Signed signature authorization for block 12 and 13 only on file.
P	Signature generated by provider; customer was not present for service.

Note: Default is “B”.

Provider’s Signature on File

Checked if Yes.

Unchecked otherwise.

Claim Documentation is at Provider’s Site

Checked if Yes.

Unchecked otherwise.

Are You Rendering Emergency Care

Checked if Yes.

Unchecked otherwise.