Where would the provider representative signature go on the UB-04 claim form?
The provider representative signature is no longer required on the UB-04 claim form. Although the signature is not required, it should be noted that the back of the claim states the following: “THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM , MAY SERVE AS THE BASIS FOR CIVIL MONETARY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW. Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate, and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: 8. For Medicaid proposes: The submitter understands that because a payment and satisfaction of this claim will be from Federal and State funds, any false statements , documents, or concealm
