| Name | Value |
|---|---|
| NAME | N-HCFA 1500 BOX 12 |
| SECURITY LEVEL | NATIONAL,NO EDIT |
| TYPE OF ELEMENT | CONSTANT VALUE |
| ELEMENT CATEGORY | INDIVIDUAL ELEMENT |
| BASE FILE | BILL/CLAIMS |
| CONSTANT VALUE | SIGNATURE ON FILE |
| DESCRIPTION | PATIENT'S OR AUTHORIZED SIGNATURE FOR RELEASE OF INFORMATION TEXT |