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Medicare Signature Attestation Statement (CGS)

When a Medicare reviewer finds a medical record entry or order with a missing or illegible signature, the author can sign an attestation statement so the entry counts in medical review. CGS, the DME MAC for Jurisdictions B and C, posts a suggested one-page format based on Program Integrity Manual chapter 3, section 3.3.2.4. Using this particular template is optional.

Who completes it

Only the physician or practitioner who wrote the record entry or order completes and signs it, entering their full name, credentials and the date of service. Reviewers reject attestations signed by anyone else, even a partner in the same group practice.

Submitting and payment

How to submit it
Return the signed statement to the supplier or provider that asked for it, which sends it with the records the MAC or other reviewer requested. For a standard written order, the supplier must obtain it before submitting the claim.

Good to know

  • A valid attestation must be signed and dated by the author and contain enough information to identify the beneficiary; the template asks for the patient's name and Medicare number.
  • Reviewers will not consider an attestation when there is no associated medical record entry. It authenticates an existing note or order; it cannot replace a missing one.
  • When an order must exist before an item is delivered, the attestation counts only if the supplier obtained it before delivery. Stamp signatures are generally not acceptable to Medicare.
  • A signature log listing each author's printed name, initials and credentials is the other common way to resolve illegible signatures. CGS posts the attestation for both Jurisdiction B and Jurisdiction C.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Record Signature Attestation Statement

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can a colleague sign a Medicare signature attestation for another physician?

No. CGS states that reviewers will not consider an attestation signed by anyone other than the author of the medical record entry, even a partner in the same group practice. The author prints their full name and credentials, names the date of service being attested, and signs and dates the statement.

Is the CGS signature attestation form required?

No. CGS and CMS say both the use of this form and the submission of an attestation are optional. It is a suggested format, and any attestation that meets CMS requirements is considered. For orders, CGS notes the sample wording may need adjusting to describe the order rather than a visit note.

Is an attestation signed after the claim still accepted?

Reviewers consider attestations that meet CMS requirements regardless of when they were created, except where a rule requires the signature before a given event or date. For a standard written order, the supplier must have the attestation before claim submission, or before delivery when the order is required before delivery.