Box 12. Have the patient or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the patient or other authorized person on file authorizing the release of any medical or other information necessary to process this claim.
Box 13. Have the subscriber or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the Member or other authorized person on file authorizing assignment of payment to you.
Box 14. Enter the date of injury or medical Emergency. For conditions of pregnancy enter the LMP. If other conditions of illness, enter the date of onset of first symptoms.
Box 24 The 6 service lines in section 24 have been divided horizontally to accommodate submission of both the NPI number and BCBSNC identifier during the NPI transition, and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. Use of the supplemental information fields should be limited to the reporting of NDC codes. If reporting NDC codes, report the NDC qualifier “N4” in supplemental field 24a followed by the NDC code and unit information (UN = unit; GR = Gram; ML = Milliliter; F2 = International Unit).