Whose Signature is Needed?

Another form requiring my signature landed on my desk. This time, the form was for a CPAP machine for one of my patients. Underneath the line where I was supposed to sign my name, the form said Physician signature. Never wanting to claim to be a physician, I always cross out the word Physician and then sign my name with NP written clearly after it. This time, I also decided to call the durable medical supplier and gently suggest that the term provider might be more appropriate and inclusive and asked if the company might consider changing the wording on the form. I was transferred to someone else, who was able to help me; within a few hours, I received a fax of the new-and-improved form, which showed the change in wording that I had requested. When I made this request, I didn’t do it in a demanding way but, rather, in the form of a gentle suggestion.

A week later, I made a similar request of a person working at the breast care center of one of our referral hospitals. This person was also accommodating, and agreed to make this change on the center’s form. I have since made this request of persons working at pharmacies, boarding homes, and even the bureau of motor vehicles (our state has passed a law saying that NPs can sign its forms, but the signature line still says Physician). I don’t succeed every time, but the more often I effectuate such a change, the more I want to try to do it again. On occasion, I call someone and it’s not quite as easy or the person says that the request must go “up the chain” to the national office. I thank the person for handling this request for me, ask for his or her name, and ask that he or she have a superior give me a call with a response. The interesting aspect of this process is that most of the people responsible for the wording of these forms don’t even realize that the forms lack an inclusive term, and most say that no one else has ever pointed out the problem.

The message to us NPs is that we still need to educate a lot of people about who we are and what we do, that most people are amenable to change, and that our phone calls can make change happen. These phone calls take valuable time to make, and most of us are very busy! But, in the process, not only are the forms changed to reflect the fact that not all health-care providers are physicians, but also more people learn about us and our profession.

Some states have passed legislation providing for global signature authority for nurse practitioners. This legislation doesn’t necessarily change the signature-line wording on forms, but it allows NPs (and often nurse-midwives, clinical nurse specialists, and other APNs) to sign, certify, stamp, verify, or endorse medical papers and records within the APN’s scope of practice (SoP) when a physician’s signature is required. This legislation doesn’t change the SoP, but it does allow NPs to sign forms asking for a physician’s signature if what is signed for is within the NP’s SoP. This method still doesn’t make the language more inclusive, but it does make it legal for an NP to sign when a physician’s signature is requested.

Federal law still requires a physician’s signature on forms for Medicare home health and hospice. This limitation isn’t an educational issue but, rather, a legislative issue. In this situation, we need to work with our state and national NP organizations to encourage legislators to make this change. A lot of effort has been put forth by NP leaders and organizations, and some legislators are sympathetic to this cause. Effectuating this change will require continued effort; if you receive a request to contact your legislators about this issue, please do respond.

I have found that some companies, primarily disability insurance companies and mortgage insurance companies, require a physician’s signature and will deny a claim if an NP signs the form. I have called people working for these companies, who tell me that the contract with their client specifically states that a physician must verify the patient’s condition. This situation poses different challenges, because the insured has signed a contract stating a physician will be the one signing the form or verifying the condition.

A similar issue—one that relates not to signatures but to identity—is that I receive letters from consultants to whom I have referred patients for further care, but the letters address me as “Tom Bartol, PA.” To me, this mistake is always worth a phone call to the letter writer to gently educate him or her that I am an NP, not a PA, and that we are not the same. Many physicians have never understood the difference between an NP and a PA and therefore conflate the two professions. This misunderstanding provides us with an opportunity to broaden their horizons.

I encourage you to take the steps that are needed so that healthcare company personnel use inclusive terms when asking for signatures, and that healthcare colleagues understand the difference between NPs and PAs. You may not have the time and resources to make this effort in every situation. But please be sure to do so at least some of the time. Make a call or send a letter with a gentle reminder or suggestion. You will see results, and people will become more knowledgeable about who we are as NPs and what we do. Seize the opportunity to promote the NP profession whenever you can.

Tom Bartol can be reached at bartol @gwi.net