Signature Log Template

SIGNATURE LOG

Legible Name

Legal Signature with

Any Signature

Credentials

( Print / Type )

Credentials

Variations

Unacceptable Physician Signatures & Credentials

Unacceptable Unless …

1. The provider authenticated Typed Name.

2. Non-Physician or Non-Physician Extender co-signed by acceptable physician.

3. Provider of Services’ Signature without Credentials Name linked to provider credentials or name on physician

stationary.

4. Illegible Signature verified from a signature log.

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Parent category: Miscellaneous